Nurses' perceptions of engaging in internet‐based nursing services: A qualitative study based on three hospitals in China

Abstract Aim In response to the ageing population and shortage of human resources for nursing care, China is piloting internet‐based nursing services (nurses who provide this care are called online nurses). Nurses are the providers of this model, so it is important to understand their perceptions. We aim to explore nurses' perceptions of engaging in internet‐based nursing services. Design This study is descriptive qualitative research, so the data were analysed using a descriptive qualitative research method based on the theory of planned behaviour, using thematic analysis. Methods With personal semi‐structured interviews conducted by two Master of Science in Nursing with 18 online nurses and nine clinical nurses, terminated after information saturation. Results Nurses' emotional attitudes towards internet‐based nursing services were generally positive, but their behavioural intentions were negative. Social support, hospital organisational climate and family responsibilities had a statistically significant impact on nurses' behavioural decisions. Internet‐based nursing services place higher demands on nurses' knowledge and skills, and nurses are most concerned with ensuring patient and nurse safety. Patient or Public Contribution No Patient or Public Contribution.

however, the shortage of nurses has been a worldwide health challenge (China, 2019a;Lancet, 2020). The questions of how to meet the growing demand for nursing services in the context of ageing and how to ensure successful ageing of older adults in the face of a nursing shortage are pressing challenges.
The development of the internet provides an excellent opportunity to reform and rethink the health and social security system of China, which is currently implementing internet-based nursing services (nurses who provide this care are called online nurses; China, 2019b;China, 2019c). The hospital uses its own Registered Nurses and relies on the internet to provide care in the mode of 'online application and offline service'. Patients place orders through the application (App; such as 'Gold Nurse', 'Medical Care Home', 'Nurse Home'), Nurses take orders according to their qualifications and abilities and use their free time to address orders instantly. The management personnel choose the best matches for the orders via the information platform based on comprehensive factors, including nurses' qualifications, professionalism and distance. The nurses travel to patients' homes or designated locations by means of transportation, such as bicycles, cars, buses. They provide care services with respect to chronic disease management, rehabilitation care, special care, health education and hospice care for older or disabled patients, patients undergoing rehabilitation and terminal patients with limited mobility (China, 2019d). The care services currently provided include blood collection, intravenous infusion, intramuscular injection, subcutaneous injection, insurance services, general dressing change, catheterization, indwelling gastric tubes, peripherally inserted central venous catheters (PICC), medication exchange, enemas, suction, perineal care, stoma care, postnatal care and neonatal care Ren et al., 2020).
Internet-based nursing services are immediate, random and disposable, eliminating the time and space constraints of traditional care models, thereby maximising the human resources available for nursing and meeting the health needs of the population while increasing risks and challenges (Zhao et al., 2021;Zhao et al., 2022).
Nurses are the main providers of internet-based nursing services and only by fully understanding their views can targeted measures be taken to motivate them to participate and achieve the sustainability of the model (Hu, 2021). Relevant studies have already conducted cross-sectional surveys of nurses' perceptions and attitudes Li, Zhao, et al., 2020;Sheng et al., 2020). However, very little is currently known about the individual perceptions of nurses. Theory helps to explain and predict behaviour. The theory of planned behaviour consists of three basic elements: attitudes, subjective norms and perceptual behavioural control (Ajzen, 1991;Godin & Kok, 1996). Attitudes refer to the positive or negative feelings that individuals experience with respect to adopting a particular behaviour and are conceptualised as an evaluation of that particular behaviour, such that attitudes are often viewed as a function of the individual's beliefs regarding the outcome of that behaviour.
Subjective norms are social pressures that individuals feel with respect to their decision to adopt or not adopt a particular behaviour, and individuals or groups that influence behavioural decisions play an important role in determining whether individuals adopt a particular behaviour. Perceptual behavioural control is a reflection of an individual's past experiences and expected obstacles, and the more resources and opportunities an individual believes that he or she possesses and the fewer obstacles he or she expects, the greater that individual's perceptual behavioural control over behaviour.
The objective of this study was to explore nurses' perceptions of engaging in internet-based nursing services based on three essential elements of the theory of planned behaviour. This study provides new insights into nurses' perceptions of engaging in internet-based nursing services. These findings can inform future policy development and research directions.

| Design
The study used a descriptive, qualitative design and data were collected through semi-structured individual interviews. We received Research Ethics Committee approval from Shandong Provincial Hospital Affiliated to Shandong First Medical University (22CGLJ36).

| Study participants
This study was conducted in three general hospitals in China. Using a purposive sampling method, we recruited online nurses who had engaged in internet-based nursing services for at least 6 months. To ensure that a wide range of attitudes and perspectives were represented, we selected online nurses according to the maximum variation strategy based on participant information such as age, gender, years of experience, job title and department, and we also included nurses who were eligible for online nurses but did not apply to participate. The study sample size was based on data saturation.

| Data collection
The literature relevant to the purpose of the study was reviewed, and a preliminary outline of the interview was developed after thorough discussion among subject group members. Two nurses were selected separately for pre-interviews, and the interview guidelines were then revised according to the results of these interviews to develop a formal interview outline (see Appendix A). Semi-structured interviews were used to collect data, and times for the interviews were established by consulting the respondents in advance. The researcher established a good communication relationship with interviewees in advance via the hospital. The purpose and statistically significance of the study and the confidentiality of the interviews were explained before the interviews, and participants' consent was obtained by asking them to sign an informed consent form regarding the recording of the interview. The nurses were interviewed individually. This was a 2:1 interview. Two researchers interviewed one nurse, one asked questions while the other took brief notes.
We conducted the interviews face-to-face. Two Master of Science in Nursing students conducted the interviews. All interviews were conducted by the researcher in a quiet and distraction-free environment. During the interviews, the researcher listened carefully, maintained a neutral attitude, encouraged interviewees to express themselves fully, and observed and recorded their nonverbal communication. Each interview lasted 30-50 min, with the interviewer writing a reflective journal at the end of each interview to improve the quality of the interview. The interviews achieved data saturation after the 16th online nurse had been interviewed; two more online nurses were interviewed, and no new information emerged, resulting in a total of 18 online nurses interviewed. Semi-structured interviews were conducted with corresponding clinical nurses, and data saturation was achieved by the seventh clinical nurse, with no new information emerging from interviews with two other clinical nurses, resulting in a total of nine clinical nurses interviewed.

| Data analysis
Within 24 h of the interviews, two researchers independently transcribed the content of the audio recordings and returned these transcriptions to interviewees for confirmation of the interview content; subsequently, the data were analysed by two people simultaneously.
The interview data and the audio recordings were read carefully and repeatedly, and the interviewees' words, expressions and movements were recalled in order to analyse and extract statistically significant content; recurring words were coded and identified, and themes were summarised and distilled; interviewees were consulted regarding points of disagreement for verification purposes. At the end of the data analysis, the subject group listened to the recordings once again to correct and review the preliminary analysis of the interview data and ensure the accuracy and precision of the analysis results.
As this research is guided by a theoretical framework, data collection tends to be more structured than in the case of many other qualitative studies, and the analysis process tends to be more explicit. The analysis was conducted via thematic analysis (Braun & Clarke, 2006;Vaismoradi et al., 2013) and included the following steps: (1) familiarise yourself with the data: transcribe the data and read the data to jot down initial thoughts; (2) generate initial codes: systematically code interesting features of the data across the dataset, collating data associated with each code; (3) search for themes: collate the codes into potential themes and collect all data associated with each potential theme; (4) review the themes: verify that the themes are relevant to the coded extracts and the entire dataset, generating a theme map; (5) define and name the themes: perform ongoing analysis to refine the details of each theme and the overall narrative of the analysis,

| Participants
The basic characteristics of the participants are shown in Table 1. A total of 27 nurses were recruited, of whom 18 were online nurses and 22 were female. The average age of the participants was 34 years, and the average length of work was 10.6 years. Frequently provided services were intramuscular injection, subcutaneous injection, intravenous blood collection, urinary catheterization and indwelling gastric tubes.

| Attitudes
Nurses' emotional attitudes towards internet-based nursing services were generally positive, but nurses' behavioural intentions were negative (Table 2). Nurses said that internet-based nursing services met the diverse health needs in the context of ageing and fulfilled the attachment of older patients to their homes. It reduces the time of patients' hospital visits and the risk of in-transit, especially during a regular epidemic, and the model greatly reduces the risk of crossinfection. In addition, the project can improve the professional identity of nurses and broaden their career paths. However, the working model of internet-based nursing services conflicts with the recreational life of nurses, and some nurses fear being stigmatised by the pornographic industry. Coupled with insufficient publicity and popularisation, some nurses do not understand or even misunderstand the specific content, such as nursing service authority, nursing service form, remuneration. In addition, internet-based nursing services are in a pilot stage, immature and with many risks, for example, road safety, the prevention of occupational violence, and the treatment of critical condition changes caused by home nursing procedures and nurses' willingness to act are shown to be neutral and wait-and-see.

| Subjective norms
The subjective norms of nurses are influenced by three areas: social support, hospital organisational climate and family responsibilities (Table 3). Currently, there is a lack of legislation related to internet-based nursing services, insufficient research on policy content and economic conflict between nurses and patients. In addition, internet-based nursing services are not sufficiently motivating for hospitals, hospitals place less importance on them, nurses lack a voice in leadership, chief nursing officers and colleagues have indifferent attitudes, nurses want internet-based nursing services to be integrated with the performance appraisal system and promotion system, and they expect assistance from multidisciplinary teams to support and give full play to the role of primary nurses. In addition, younger nurses are more willing to participate in internet-based nursing services to subsidise their families, but this conflicts with the qualification requirements in the policy. For middle-aged and older nurses, internet-based nursing services conflict with the family roles that nurses play as wives, mothers and daughters.

| Perceptual behavioural control
Nurses possessed solid basic knowledge and conventional nursing skills, but internet-based nursing services placed higher demands on nurses' knowledge and skills, and ensuring the safety of nurses and patients was a core concern of nurses ( Table 4). The unfamiliar and rudimentary home environment greatly increased the difficulty of nursing operations, and nurses emphasised the importance of communication skills and emergency response abilities, arguing that online nurses need to be uniformly trained and certified. In addition, there is a risk to breaching confidentiality of patients' personal data and health information, and there are many patient safety risks due to the distance from standardised wards, the fact that the source of medicines and medical consumables has not been standardised and the lack of resuscitation equipment and medicines. At present, the personal safety and transport safety of nurses cannot be guaranteed and there is an urgent need to improve patient identification and accident insurance for nurses.

| DISCUSS ION
Our study found that nurses' affective attitudes towards internetbased nursing services were generally positive, with nurses believing that internet-based nursing services, which have been introduced in the context of an ageing population and which make TA B L E 1 Basic characteristics of participants. Looking forward to having the support of a multidisciplinary team to assist N5: 'The catheter had been successfully inserted and the patient had not been able to urinate and the patient was in distress […] it took a phone call to a urologist I know for advice to get the problem sorted out'.
Integrated with the performance appraisal and promotion system N19: 'Apart from their own work, nurses focus more on writing articles and declaring topics because it is closely related to promotion […] and only by linking internet-based care services to performance and promotion will more nurses be attracted to join'.
Making the most of the role of the primary nurse N16: 'Internet-based care services should be more often undertaken by nurses from secondary or community hospitals […] but due to their lack of capacity, they are currently mostly nurses from tertiary hospitals'.

Family responsibilities
Conflicting wishes and qualifications of young nurses N7: 'For middle aged and older nurses who meet the qualification requirements, who have worked for many years and are financially stable, this salary is not attractive enough, younger nurses need this salary more […] but younger nurses do not meet the policy requirement of 5 years' experience'.
Conflict with family roles N16: 'Every time I take an order during my time off, my husband will drive me, which means warmth and guilt […] I need to play the multiple roles of wife, mother and daughter, they are the most important in my heart and I need to spend more time off to be with them and take care of them'.
internet-based nursing services to motivate middle-aged and older nurses to engage in internet-based nursing services in a more positive way.
The randomness, immediacy and disposability of internet-based nursing services can maximise the use of nursing human resources, but the specificity of the service site and the unpredictability of the population and the emergencies they face also increase safety risks for nurses and patients (Xie, 2019;Zhao et al., 2021). Such services should be demand-driven and refined in terms of theoretical disposal, risk warning awareness, rapid response capability and first aid techniques; in addition, such services should seek to develop practical, scientific and quantitative training programmes to improve the professionalism and qualifications of nurses (Shen et al., 2021;Xv et al., 2020;Zhao et al., 2022).
Currently, nurses are predominantly female and work alone. If they are unable to accurately grasp patients' personality traits and assess the characteristics of their social support system, in addition to the fact that patients may have high treatment expectations or perceptions of the connection between medical care and nursing, the occupational or even personal safety of nurses can be difficult to guarantee in the event of medical disputes or medical incidents (Han et al., 2020;Wang et al., 2019). For patients making their first appointment, the hospital and the platform must first confirm and assess their illness, operation needs, identity and service location and confirm the service distance, service time and service location involved before sending the online nurse to provide the relevant care service. In addition, it is necessary to ensure that the location of online nurses is tracked accurately and that police officers are able to respond in a timely manner after an duress device is triggered; it is also important to purchase personal accident and medical accident insurance for online nurses (Hu et al., 2019).

| LI M ITATI O N S
This study faces several limitations. First, all respondents were nurses from three tertiary general hospitals in Shandong Province, so the results may not be generalisable to other provinces and lowerlevel hospitals. Second, we did not interview staff from other units regarding their perceptions of internet-based nursing services, such as doctors and staff from third-party platforms. Finally, it is critical to explore patients' perceptions of internet-based nursing services directly and to investigate whether patient experiences of internetbased nursing services and their potential limitations and benefits are consistent with those expressed by nurses.

| CON CLUS IONS
This study explored nurses' perceptions of engaging in internetbased nursing services based on three basic elements of the theory of planned behaviour. Our study found that nurses' affective attitudes towards internet-based nursing services were generally positive, with nurses believing that internet-based nursing services, which were introduced in the context of an ageing population and which make use of the internet under governmental guidance, and the shift from a hospital care model to a home care model met patients' diversified health needs, enhanced nurses' professional mission and sense of identity and broadened nurses' career development paths. However, nurses' willingness to act was negative, with nurses believing that the model is still in a pilot phase and that problems such as a lack of laws and policies, a lack of incentives, family role conflicts and hidden risks to patient safety still need to be addressed. These findings can influence future policy development and research directions. Future research should focus on ways of addressing the challenges faced by nurses who participate in internetbased care services.

AUTH O R CO NTR I B UTI O N S
Baosheng Zhao and Wei wang was responsible for designing the study, conducting the interviews, interpreting the data and drafting the text. Mo yi was responsible for conducting the interviews and interpreting the data. Hong Lv was responsible for interpreting the data. XiaoMan Zhang was responsible for interpreting the data. Yujie Liu was responsible for interpreting the data. Xinhong Song was responsible for designing the study, critical review of the intellectual content of the article, support and guidance. All authors reviewed the manuscript.

ACK N O WLE D G E M ENTS
Confirmed by all authors.

I declare that the authors have no competing interests as defined by
Nursing Open or other interests that might be perceived to influence the results and/or discussion reported in this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

E TH I C S S TATEM ENT
We obtained approval from the Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical University. (2021259).