Core competencies and perceived training needs of nurses in the background of Internet plus nursing service: a qualitative descriptive study†
Article Category: Original article
Publié en ligne: 26 juin 2024
Pages: 181 - 190
Reçu: 03 mai 2023
Accepté: 22 janv. 2024
DOI: https://doi.org/10.2478/fon-2024-0019
Mots clés
© 2024 Wei-Wei Liu et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
An aging population is a widespread global phenomenon, which is developing rapidly in China. The elderly population of 60 years and above was 264.02 million in China, accounting for 18.70% of the total population in 2021. Among them, the population aged 65 and above was 190.64 million, accounting for 13.50%.1 The elderly over 65 years old have a high incidence of multiple chronic diseases; about 2/3 of them have comorbidities.1 With the increasing number of the empty-nesters, and people with dementia and disabilities, there is a huge demand for home nursing services.2 By the end of 2021, there were 5.01 million registered nurses in China, with only 3 nurses per 1000 population, which could not meet the increasingly diverse health needs of the people of the country.3 Therefore, the gap between the supply and demand for home nursing services becomes prominent. To actively respond to the aging population and increase the supply of home nursing services, the Chinese government has piloted the Internet plus nursing services program in 6 provinces, including Beijing and Shanghai since February 2019.4,5
Internet plus nursing service refers to the home nursing service provided by registered nurses from medical institutions. It relies on the Internet platform to serve discharged patients or individuals with comorbidities and functional impairments, operating in the mode of “online application and offline service.” That is, clients choose service items to place orders through mobile applications. Registered nurses practicing in medical institutions independently receive orders through the network in their spare time and then visit clients’ homes to provide home visiting care, which includes intravenous injections, intramuscular injections, urethral catheterization, and gastric tube insertion and replacement.6 Home visiting has been well practiced in the United States and other developed countries, while the Internet plus nursing service is based on the development of the sharing economy in China, and it represents a new health care model that differs from the traditional home visiting practices. Nurses participating in Internet plus nursing services in China are registered nurses employed by medical institutions, who receive applications on the platform in their spare time and provide home nursing services on a part-time basis.7 In contrast, nurses in developed countries who provide home care services are mostly affiliated with specialized home care agencies and tend to work full-time. They establish long-term, stable nurse-patient relationships with their clients.8 In addition, in the context of Internet plus nursing, the way in which the nurse delivers care is different, as it involves an information and communication technology-based telehealth service. Nurses need to overcome many uncertain challenges when conducting face-to-face home visits because they have worked in medical institutions for a long time and have little experience in providing home care. Additional knowledge and skills are required.9 Internet plus nursing services have been proved to reduce hospitalization frequency among the elderly, improve satisfaction, promote the extension of high-quality nursing resources to communities and families, and improve nurses’ income and practice value.10,11 Due to the changes in the workplace and particularly the emergence of the Internet plus nursing service, nurses need to face an uncertain, risky environment, which puts greater stress on their expertise and competencies.12 However, it is still unclear what core competencies are required for nurses engaged in Internet plus nursing services, making their training difficult to implement.
Previous studies explored the work experience of nurses6,13 and implementation barriers7 in Internet plus nursing services. Due to the lack of professional training, most nurses generally had insufficient confidence at the beginning of the service, and showed negative emotions such as tension and worry, which seriously affected their enthusiasm to participate in the Internet plus nursing service program.13 According to Zhao et al.7 the uneven service quality of nurses was an important hindering factor for the elderly to receive Internet plus nursing services. Moreover, family caregivers similarly expressed concerns about the safety of home care services and the uncertain risk of nurses’ practices.14 Therefore, there is an urgent need to identify the core competencies and training needs of nurses and conduct training programs, so as to build the professional competence and confidence of nurses and improve the quality of Internet plus nursing services. However, little is known about core competencies and training needs of nurses engaged in Internet plus nursing services.
The purpose of our study was to understand the views of nurses engaged in Internet plus nursing services on their core competencies and training needs, and to provide a reference for developing reasonable training programs, so as to ensure high-quality and professional Internet plus nursing services.
We employed a descriptive design, which can truly reflect the views of different nurses.15 Participants were invited to share and reflect on the competencies and training needs for engaging in Internet plus nursing services. The Consolidated criteria for reporting qualitative research (COREQ) guidelines have been used for transparency reporting.16
This study was conducted in a tertiary Grade A hospital implementing Internet plus nursing service in Beijing from September 2020 to December 2020. Participants were purposively selected to allow for maximum variation in age, working years, and the number of home nursing services as much as possible. Inclusion criteria were as follows: nurses who have been engaged in Internet plus nursing service for more than one month, who agreed on the study plan and signed the informed consent form. Nurses who were taking a refresher course, on leave, or away from clinical duties during the interview were excluded. Recruitment stopped when no new codes and themes emerged from the data.17 A total of 15 participants were interviewed, and no participants refused to participate or withdrew during the study. Their demographic characteristics were detailed in Table 1.
Participants characteristics (
| Participants | Age (year) | Working years | Professional title | Position | Department | Number of home nursing services |
|---|---|---|---|---|---|---|
| P1 | 39 | 15 | Supervisor nurse | Nurse | Orthopedics | 10 |
| P2 | 30 | 7 | Senior nurse | Nurse | Geriatrics | 13 |
| P3 | 37 | 15 | Supervisor nurse | Head nurse | Pneumology | 30 |
| P4 | 28 | 7 | Supervisor nurse | Nurse | Urology | 2 |
| P5 | 29 | 8 | Senior nurse | Nurse | Oncology | 6 |
| P6 | 35 | 16 | Supervisor nurse | Nurse | Respiratory intensive care | 3 |
| P7 | 31 | 10 | Supervisor nurse | Nurse | Pneumology | 10 |
| P8 | 35 | 12 | Supervisor nurse | Nurse | Cardiovasology | 30 |
| P9 | 30 | 7 | Supervisor nurse | Nurse | Neurosurgery | 10 |
| P10 | 31 | 7 | Supervisor nurse | Nurse | Pneumology | 15 |
| P11 | 32 | 10 | Supervisor nurse | Nurse | Pneumology | 20 |
| P12 | 38 | 15 | Supervisor nurse | Nurse | Gastrointestinal Surgery | 3 |
| P13 | 30 | 10 | Supervisor nurse | Nurse | Pneumology | 20 |
| P14 | 45 | 23 | Associate chief nurse | Head nurse | Pneumology | 15 |
| P15 | 35 | 12 | Supervisor nurse | Head nurse | Geriatrics | 10 |
The two researchers (QZ, ZC) who were trained in qualitative research confirmed the time and place of the interview with the participants. The interview was conducted in the nurse’s lounge. No one else was present except researchers and participants. The interview guide was preliminarily formulated according to the purpose of the study, and it was revised based on pre-interview with 2 participants: (1) What core competencies should be available for the nurses engaged in Internet plus nursing services? (2) What training you need before providing home nursing services? Each interview lasted 40–60 min, and the whole process was recorded. During the interview, the researchers closely observed and recorded the verbal behaviors, such as verbal pauses, facial expressions, and actions. A total of 18 face-to-face, semi- structured, and in-depth interviews were completed, including 1 supplementary interview for 3 participants.
The researcher (ZC) transcribed the interview, converting the recording into text within 24 h after the interview, and then returned the collated data to the participants for verification and confirmation. We used thematic analysis inspired by Brown and Clark18 to analyze the data: (1) Read the transcribed text repeatedly; (2) Extract repeated points in the data and encode them with phrases or sentences; (3) Condense codes with similar or related meanings to generate themes/subthemes; (4) Re-review the themes/sub-themes and compare them with the original data continuously; (5) Name the themes in concise language; (6) Write the data analysis process.
The trustworthiness of this study was estimated according to the 4 criteria of credibility, transferability, reliability, and confirmability19.
The transcript of participants was appropriately quoted when reporting the results of this study. QZ and ZC reviewed the data repeatedly and independently, and discussed the results of data analysis with other members of the research group on a regular basis regarding inconsistencies in the coding.20
We used the maximum variation principle to select participants with a wide range of characteristics, including age, working years, and the number of home nursing services, to facilitate the transferability of the results.21
Details of record design, participants, and data collection and analysis.22
Researchers maintained a neutral attitude during data collection to avoid the inducement of fear in participants. We provided all researchers with the original transcript of the interview, as well as the extracted codes and categories.23
The study was conducted according to the Helsinki Declaration24 and approved by the Ethics Committee (Reference number: Z2022SY059). Before the interview, participants were fully informed of the research purpose, significance, and necessity of recording. We promised to keep their information strictly confidential, and assured that all information collected would be for study use only. Participants were informed that they could voluntarily participate in or withdraw from the study. The study obtained both oral and written informed consent from the participants.
In total, 2 themes and 11 subthemes were refined in this study.
Before entering the household, nurses only knew about the clients from the registration information on the Internet platform. Only by conducting a more comprehensive assessment can they collect the overall situation to clarify the nursing plan as early as possible. This includes checking the registration information of clients in the service platform, pre-entry telephone assessment, and pre-operation assessment.
Participants agreed that participating in Internet plus nursing services, nurses should have the ability to directly provide nursing practice and help home-based patients solve practical health problems. They mentioned that performing services alone in the clients’ home environment required them to have more solid and stable nursing practice competencies to ensure the implementation of the same quality of services.
Participants stated that most clients and their families often ask about health-related concerns beyond the scope of the provided services, which required them to have deep competence in health education and counseling to adequately address the clients’ information requirements.
Participants emphasized risk estimation and response as an important competence. Unlike the service process in medical institutions, there were various potential risks in Internet plus nursing services. Nurses expressed the great necessity to use their risk evaluation competence to take early preventive measures in resolving challenges such as adverse drug reactions, complications, or potential emergencies.
Participants affirmed that good communication competence could help them flexibly cope with various communication scenarios, such as initially establishing a relationship with clients, answering clients’ questions, or responding to emergencies.
Although the selected participants had over five years of clinical work experience and proficiency in nursing techniques, they still expected to be trained in some specific and complex operational items before implementing the Internet plus nursing services. Participants believed that it was stricter to perform nursing technology independently in the home environment and that the training might be strengthened based on the differences between nursing technology in the home and medical institutions environment, as well as the precautions taken during the home operations.
Clients of Internet plus nursing services often belonged to vulnerable populations, including the elderly and those with chronic illnesses. However, nurses engaged in Internet plus nursing services in China specialize in a particular area, resulting in a relatively limited scope of knowledge. Participants asserted that their knowledge reserves directly affected the effectiveness of patient health education, and that they had a large training demand for knowledge related to chronic disease management. They hoped to constantly update their knowledge in order to maintain their professional competence and optimize the quality of service and patients’ medical experience.
Participants expressed their desire to strengthen the training in risk assessment and prevention in order to make them aware of the potential risks of Internet plus nursing services and coping strategies, especially the exercise of emergency plans.
Participants noted that familiarity with relevant systems and standardized procedures was a prerequisite for carrying out Internet plus nursing services, which could help them provide safe and standardized care for their clients.
Participants considered that communicating with unfamiliar families and employing communication strategies in emergencies were their weaknesses. To address these challenges, they suggested that the training content should include common professional communication skills and methods in emergencies.
Different from the home care services provided by community nurses, Internet plus nursing services mainly rely on the network information platform. Therefore, participants emphasized a need for practical hands-on training on the use of information technology before the implementation of Internet plus nursing services and after the software updates to get familiar with the service process and improve the work confidence.
Through continuous analysis, we finally formed a conceptual framework for core competencies and training needs of nurses engaged in Internet plus nursing services (Figure 1). Core competencies involved comprehensive assessment competence, direct care practice competence, health education and consulting competence, risk estimation and response competence, and communication competence. Training needs involved complex operational items, knowledge of chronic disease management, professional communication, risk identification and prevention, nursing standards, norms, and procedures, and utilization of information technology.
Figure 1.
Conceptual framework for core competencies and training needs of nurses engaged in Internet plus nursing services.
This qualitative study explored the cognition of nurses engaged in Internet plus nursing services about the core competencies and their training needs. The results of this study were consistent with the core competencies of the family and community nurses.25 The findings may provide a reference for managers to evaluate the ability of nurses participating in Internet plus nursing services and formulate their training plan.
Among the clients of Internet plus nursing service, a tiny percentage of them were hospitalized in the wards nurses worked, but most were completely unfamiliar with the nurses. Therefore, the comprehensive and accurate assessment of patients is the premise of mastering the patient’s condition and implementing comprehensive nursing plans successfully. Previous studies have reported similar findings that the comprehensive assessment of patients with chronic diseases could predict the possible risks during home services, enabling targeted risk management.26,27 It is suggested that managers may design comprehensive patient assessment tools and embed them into the Internet platform to help nurses conduct comprehensive assessments and fully understand the patients’ condition before entering households.
Due to changes in the working environment, lack of peer support, and increased patient expectations, nurses may face multiple pressures during the service process.28 Nurses engaged in Internet plus nursing services are expected to have solid nursing practice competencies to improve work confidence, so as to ensure the stable implementation of nursing technology and flexible response to all kinds of problems that may occur in Internet plus nursing services. This is consistent with Furaker et al.29 who concluded that nurses need professional practice skills to make independent decisions and address patient concerns in the home environment. Therefore, managers could take direct nursing practice competence as the key assessment criterion when selecting nurses.
The importance of health education competence was emphasized for helping patients receive advice related to self-management, reducing the incidence of out-of-hospital adverse events, readmissions, and the burden of caregivers.30–32 During the process of home-based chronic disease management, patients usually encounter multiple nursing-related knowledge problems. Nurses might have remarkable knowledge, outstanding education and consultation competence, and then make health education plans to meet the clients’ information needs.
The ability of nurses to communicate with clients has been recognized as a crucial factor in establishing the trustful relationship and exchanging information. Timely and effective communication could improve client satisfaction and foster their compliance with treatment to achieve better therapeutic effect.33,34 The Japan Visiting Nurses Association has taken communication as a core component of home care training.35 In the client’s home, it is more complex for nurses to build a trust relationship compared to the medical institutions. Markkanen et al.36 found that compared with receiving nursing services in medical institutions, patients tend to have more initiative and a sense of empowerment when receiving nursing services at home. They also had higher expectations for the professional level of nurses and were more prone to medical disputes. Some participants expressed their significant deficiency communication competence in encountering unfamiliar patients and unexpected events. Therefore, managers may develop language and behavior norms of Internet plus nursing services, along with conducting communication training for nurses to improve their conflict management skills.
Participants mentioned that clients may experience emergency situations such as changes in medical condition and adverse drug reactions during the home service; Nurses may also face various emergencies such as operation failure and occupational exposure. The nurses’ proficiency in anticipating and managing potential risks and emergencies is crucial to clients’ health, which directly affected the quality of Internet plus nursing services. In addition, a previous study has shown that most nurses providing home care services were female, who were easy to worry about their own safety when faced with the uncertainty of home environment and service population.37 Therefore, nurses may need to be trained in common risk identification and response to reduce their safety concerns.
With the increasing aging population, more and more elderly people with multiple chronic diseases choose long-term home nursing service.38 The questions they asked involve all aspects of the treatment and nursing, while nurses engaged in Internet plus nursing usually come from a certain specialty in the medical institutions, whose knowledge field has developed vertically. The participants often felt that their store of chronic disease management knowledge was inadequate. In addition, with the shortening of hospitalization days, patients with a variety of complex health problems are more willing to accept home rehabilitation. Therefore, nurses may have to provide more professional technical services, such as ostomy care, peripherally inserted central catheter (PICC) maintenance, and peritoneal dialysis care.29 Managers might formulate the operation norms of Internet plus nursing services technology, specify the precautions, and conduct unified training and assessment for nurses to ensure standardized technical operations for patients.
Establishing systems, norms, and processes is seen as essential in the safe development of Internet plus nursing services, which can enable nurses to practice within the scope of legal definition and provide homogenized services. A qualitative study by Aune and Struksnes39 identified the lack of uniform norms as one of the main barriers to implement home care services. Therefore, this suggests that managers may develop systems and regulations of Internet plus nursing services, and improve standardized procedures and standards to guide nurses to practice in compliance. In addition, participants believed that they needed training in the information technology to guide patients, which was similar to the findings of Irani et al.40 The elderly, who are the primary recipients of Internet plus nursing services, often experience poor physical functions such as memory, vision, and touch. Furthermore, the elderly know little about the Internet and mobile terminals, therefore, it is difficult for them to use intelligent technology flexibly and effectively. In the context of “Internet plus nursing,” they may face difficulties in seeking nursing services and require face-to-face guidance from nurses.
The ongoing delivery of effective and efficient Internet plus nursing service is reliant upon the development of nurses’ competencies, which requires nurses to make corresponding competencies preparation. This study deeply explored the perspective of nurses and managers with the work experience of practice in Internet plus nursing on the core competencies that they have developed and the training needs. The results established a framework for core competencies and training needs for Internet plus nursing nurses based on future occupational performance, which may provide a reference for the admittance criterion, training, and assessment of nurses, so as to promote the development and promotion of Internet plus nursing services. In the future, researchers could explore the views of Internet plus nursing clients on the core competencies that nurses engaged in Internet plus nursing should have. And researchers may carry out quantitative research to form evaluation scales of core competence and build training systems based on core competencies and training needs.
This study enhances our understanding of the nurses’ opinions on the core competencies and training content that should be developed to meet Internet plus nursing work needs. We performed sampling with maximum variation, aiming to seek the different views of participants. The interviews were carefully planned and conducted in a relaxed atmosphere to enable transparency in the process.
Several limitations should be considered. The participants only included nurses engaged in Internet plus nursing, we did not discuss the views of patients as the clients of Internet plus nursing services. In addition, the sample of this study was from a hospital in Beijing, China, which piloted Internet plus nursing services, and may not represent the views of all nurses engaged in Internet plus nursing services, and the findings may not necessarily be applicable to people from other ethnic and cultural backgrounds. We were also unable to recruit any male nurses, while the vast majority of those engaged in Internet plus nursing services are still overwhelmingly female. It is important to note that different experiences between male and female nurses may produce different perceptions.