Introduction
Diabetes Mellitus (DM) is a metabolic disease characterized by a chronic elevation of blood glucose. This elevation is caused by various factors, including genetic and environmental influences. Currently, diabetes has become the third most serious health threat to humans, following tumors and cardiovascular diseases [1]. According to the latest data from the International Diabetes Federation, approximately 537 million adults worldwide had diabetes in 2021. Among them, 140 million patients were in China, accounting for one-quarter of the total global population. China has become the country with the highest diabetes incidence rate in the world [2]. Diabetes is a disease that requires lifelong treatment, long-term monitoring, and follow-up treatment. Telemedicine technology enables remote consultation, diagnosis, and remote monitoring. It can effectively address health education, patient compliance, monitoring, and provider accessibility. Consequently, the technology is increasingly applied to diabetes management. Currently, technologies used for diabetes management mainly include Internet-based remote data transmission and monitoring systems, remote monitoring devices, online diagnosis and health counseling, and diabetes mHealth applications [3, 4]. The individuals responsible for the implementation are primarily doctors and nurses within medical institutions. Among them, the initiatives led by nurses mainly refer to Internet-mediated nurse home visits.
In China, the concept of “Internet +” was initially put forward in 2015 [5]. Subsequently, “Internet +” nursing services have gradually drawn increasing attention. In 2019, the National Health Commission of the People’s Republic of China issued two important documents. One was the “Notice on Carrying out the Pilot Work of ‘Internet Plus Nursing Service’”, and the other was the “Pilot Work Plan for ‘Internet Plus Nursing Service’”. These issues led to the implementation and realization of Internet nursing services. “Internet + Nursing Service” mainly refers to medical institutions using nurses registered in their institutions, leveraging information technologies such as the Internet, the Internet of Things, and cloud computing. It primarily operates on a mode of “online appointment, offline service”. It provides nursing services for discharged patients or individuals with specific health conditions who suffer from diseases and have difficulty in moving. The purpose is to precisely meet the diverse health service needs of the public [6]. However, the outbreak of the COVID-19 pandemic in 2020 triggered a global public health crisis. In order to effectively curb the spread of the epidemic, most countries around the world, including China, adopted strict isolation measures. As a result, the development of offline home nursing services in the “Internet + nursing services” was restricted. In contrast, online Internet nursing clinics became an important form of medical service provision as they could effectively reduce the movement and gathering of people.
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Internet-based nursing clinics serve as a modality for carrying out online nursing assessments, consultations, and specialized guidance, with videos and pictures as the media [7]. Research has demonstrated that INCS can enhance the accessibility of specialized nursing for patients with diabetes and alleviate the care and financial burdens on their families [8, 9]. Abroad, the concept of Internet-based nursing clinics does not exist. Instead, they are predominantly offered in the form of remote video consultations and telephone consultations. The research on telemedicine for diabetic patients primarily centers on appraising the application effect and conducting satisfaction surveys. The evaluation of the application effect mainly delves into the impact of telemedicine on the physiological and metabolic indices, complication rate, quality of life, and self-management level of diabetic patients [10, 11]. In terms of satisfaction surveys, the main focus is on patients’ attitudes and perceptions towards the platform design, service quality, and communication effectiveness of remote video or telephone consultations. Multiple studies have shown that diabetic patients generally have a high level of satisfaction with the video or telephone consultations of telemedicine. Moreover, most patients have expressed their intention to continue using this technology for health management [12, 13].
China’s INCS is still in the primary exploration stage [14]. Most studies have explored the construction and operation status of the diabetes INCS platform [15, 16]. Nevertheless, these studies neglected to explore the real service experiences of patients with diabetes. Patient experience is from the patient’s perspective, exploring their feelings and experiences regarding various aspects of service during their visit to the medical institution [17]. Most of the previous studies on patient experience focused on the experiences of inpatient and outpatient patients under the traditional healthcare service model. They mainly focused on developing assessment tools and exploring influencing factors [18‐20]. On the other hand, most studies regarding the Internet healthcare patient experience adopted quantitative research methods. They aimed to explore patients’ satisfaction with telemedicine. The judgment results of these investigations were simply categorized as “satisfied” or “dissatisfied”. Moreover, there were few qualitative studies on this topic. However, qualitative studies can better reflect patients’ emotional experiences and genuine feelings in the service interaction process than quantitative studies. They can more accurately reflect the real needs of patients. This study aims to understand the real experiences of diabetic patients with INCS, to explore the factors that promote and hinder the adoption of these services by patients, and to propose service improvement strategies. These strategies will provide a reference for service optimization. They also lay an essential foundation for enhancing the sustained use and satisfaction of INCS by diabetic patients.
Theoretical framework
The purpose of this study was to explore the intention and behavior of diabetic patients toward INCS, which relies on Internet information technology as an intelligent nursing service platform. So the Health Information Technology Acceptance Model (HITAM) was chosen as the theoretical framework to guide the study. The HITAM model is a model developed by Kim and Park in 2012 based on the Health Belief Model theory (HBM) and the Technology Acceptance Model (TAM) that describes how people accept and use health information technology for the process of health management [21] (Fig. 1). The HITAM consists of three main zones: the health zone, the information zone, and the technology zone. Each zone contains one kind of belief, which are behavioral beliefs (health belief and concerns), normative beliefs (a person’s motivation to use information technology), and efficacy beliefs (a person’s level of confidence in using a device and perceived judgments about the ease of use and usefulness of the device). Research has shown that the HITAM model can clearly describe individual health consumers’ behavioral intentions and usage experiences when using relevant health information technology. For example, the HITAM model largely explained the intentions of long-term multimorbid COPD patients and cardiac patients to use a home remote monitoring device. In particular, perceived usefulness and perceived ease of use significantly affected patients’ willingness to use the device [22]. Some researchers designed an interview outline using the HITAM and the Mobile App Rating Scale (MARS) as a theoretical framework and conducted semi-structured telephone interviews with 16 app users and 14 non-app users. The results found that recommendations from professionals (subjective norms) and positive interactions between doctors and patients enhanced user experience. In contrast, a lack of awareness about the role of apps, the severity of the disease, and overall knowledge contributed to reasons why users do not use the application [23]. Therefore, this study used the HITAM model as a framework to design an interview outline for diabetic patients to understand their experiences of INCS and uncover the main factors that influence patients’ behavior in using INCS.
Fig. 1
Health information technology acceptance model
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Methods
Study design, participants, and setting
This study is descriptive qualitative research. It can help to describe patients’ perceptions, causes, obstacles, and facilitators of using specialized services, which is relevant to medical and healthcare research [24]. Therefore, semi-structured interviews were conducted with 14 patients who had used INCS to clarify their real experiences. The research subjects were sourced from the endocrinology wards of the First Affiliated Hospital of Anhui Medical University. The First Affiliated Hospital of Anhui Medical University is a tertiary-level hospital in Hefei, the capital of Anhui Province, China, and one of the top 100 hospitals in China, with 4,990 open beds. The hospital’s diabetes INCS started in 2020. Patients can consult with nurses using pictures and text. Nurses have a 24-hour time limit to respond, and if there is no response within this time frame, the system automatically refunds the patient and ends the consultation. As of December 2024, the hospital had 237 users participating in picture and text counseling. Additionally, the hospital offers video counseling services, but these must be booked in advance. Besides, these services have fewer users due to their fixed schedule and lower frequency compared with picture and text counseling.
The inclusion criteria for respondents were as follows: (1) the patient was age ≥ 18 years old and diagnosed with diabetes; (2) the patient had completed counseling services in the Internet-based nursing clinics in the past 3 months; (3) the patient was conscious, able to communicate normally, with verbal expression and comprehension, and able to complete the interview independently. The purposive sampling method was used in the early stage of the study to select the research subjects according to the age, disease type, and literacy level of diabetic patients. The maximum differential sampling method was used later to select the research subjects according to the pre-interview subjects, and the sample size was determined according to the principle of information saturation. Information saturation means that during data collection, no new data emerge and information redundancy gradually occurs. In our study, data collection was discontinued when information on the subject was repetitive and new themes and sub-themes could not emerge from analyzing the information.
Interview outline
This study aimed to understand the antecedents of diabetic patients’ use of Internet-based nursing clinics and the process by which they act on their attitudes, so the group selected eight concepts in the antecedents and the moderating process based on the HITAM model. The term “perceived threat” describes how patients view their own health status and their vulnerability to illness, as well as the severity of their own illnesses. However, this variable was excluded since it would be improper to ask patients if not using the INCS would increase perceived threat, given our goal of examining their attitudes and perceptions of the INCS. Finally, Seven key concepts informed the design of the interview outline: health status, health belief and concerns, subjective norm, the reliability of health information technology (HIT), self-efficacy related to HIT, perceived usefulness, and perceived ease of use. Utilizing this initial interview outline, the researcher conducted pre-interviews with two patients diagnosed with type 2 diabetes who had independently engaged with the Internet-based nursing clinics. During the process of the pre-interviews, regarding subjective norm, when asking “What do your family and friends think about your use of Internet-based nursing clinic services?” Two participants mentioned medical staff. So we revised the question to “What do your family, friends and others think about your use of Internet-based nursing clinic services?” and added a question, “How do their perceptions affect your use of Internet-based nursing clinic services?”. Regarding perceived ease of use, when we asked, “Do you find it difficult for you to use Internet-based nursing clinic services?” The participants only focused on the problems while receiving services rather than the evaluation of the ease of the consultation process. Therefore, a new question“During the whole consultation process, how do you think about the difficulty level of the operation?”was added. Afterward, the final interview outline was formed (Table 1).
Table 1
Interview outline
Concept | Interview question |
|---|---|
Health status | How do you feel about your current health? |
Health belief and concerns | What are your main health concerns regarding your current health status? |
Service awareness and utilization | How did you hear about Internet-based nursing clinic services? What do you know about Internet-based nursing clinic services? When did you first use Internet-based nursing clinic services? What made you want to use the services? |
Subjective norm | What do your family, friends, and others think about your use of Internet-based nursing clinic services? How do their perceptions affect your use of Internet-based nursing clinic services? |
Perceived ease of use | During the whole consultation process, what do you think about the difficulty level of the operation? Did you encounter any difficulties? |
Perceived usefulness/ Reliability of HIT | What’s your opinion on Internet-based nursing clinic services? What have you gained from it? |
Self-efficacy of HIT | How well do you think you could use the Internet-based nursing clinic services independently? |
Willingness to adopt | Under what circumstances would you continue to use Internet-based nursing clinic services? |
Service improvement suggestions | What other suggestions do you have for Internet-based nursing clinic services? |
Formal interview
Patient data was collected from May to December 2022 through face-to-face interviews. The day before the interview, the researcher reconfirmed the time and place of the interview with the interviewee and communicated with the patient’s doctor or nurse in charge about the treatment and care on that day. In order to ensure that the interviews were conducted without interference or interruption from others, the interviews were scheduled in the department’s quiet health promotion classroom, avoiding meal and treatment times. Before the formal interview began, the purpose and significance of the study were explained to the patients. Then they completed an informed consent form and a general information questionnaire [see Supplementary Material 1]. After obtaining the interviewees’ consent, we turned on the pre-prepared audio-recording pen to start the formal interview. During the formal interviews, the process began with open questions to help the interviewees alleviate their nervousness, and build trust. Subsequently, the questions were gradually asked. The interviewer listened carefully to the interviewees’ expressions, encouraging them to express their opinions and perspectives. Meanwhile, the interviewees’ facial expressions, body movements, tone of voice, and other non-verbal information were closely observed. When encountering meaningful information, follow-up questions were asked promptly. Meanwhile, silence was appropriately employed to facilitate the interview, allowing interviewees sufficient time to response. Key cues like upward or downward intonations, sudden speech-speed changes, and strong tones were recorded in the space corresponding to each question in the interview outline. Before the end of the interview, the researcher reviewed the outline again to ensure that all interview questions were covered. At the end of the interview, the respondent was asked again if there was anything else to add, and we thanked the respondent and indicated the possibility of a second interview to assist in verifying the content of the study. Eventually, the interviews with 14 diabetic patients were successfully completed, with only one interview per patient, which lasted 15–20 min.
Statistical analysis
After each interview, the audio recordings were transcribed into text within 48 h, and non-verbal information was recorded where possible. The recordings were double-checked, and the transcribed textual information was imported into Nvivo 12.0 qualitative data analysis software. Directed content analysis was used to analyze the factors influencing patients’ adoption behaviors of Internet-based nursing clinics. The specific steps were as follows: (1) Drawing on the HITAM and relevant literature, extract concepts and variables as initial coding categories and define each operationally; (2) Read the interview documents verbatim, highlighting and categorizing statements relevant to HITAM; (3) Assign a new code to uncategorizable information and adjust existing coding schemes; (4) Codes were grouped into categories and subcategories according to their relevance and degree of association; (5) The categories were collated and conceptualized to form themes. The traditional content analysis approach was used to analyze patients’ service experience and experience enhancement suggestions. The specific steps were: (1) Repeatedly read and familiarize the interview material to gain a sense of the interview as a whole; (2) Extract and label relevant descriptions from patients and nurses about their experiences and perceptions of INCS; (3) Key concepts were extracted from relevant descriptions and open coded; (4) Categorize similar and related codes into themes and sub-themes; (5) After the initial identification of themes and sub-themes, the final themes were developed by checking them against each of the textual materials and considering the internal logic between the themes. Subsequently, themes and sub-themes were defined, and examples of corresponding extracts were found in the textual material of the interviews. For example, many diabetics mentioned the waiting time for INCS in interviews. After repeated reading, mark key concepts and extract semantic units to create codes such as “long wait” and “untimely reply”. By contrasting the similarities and differences across codes according to code qualities and associations, the theme “timeliness of service” was summarized. During the analysis, the emotional attitude of the interviewees towards the topic was identified based on the changes in their voice, speech rate, and intonation. For example, a strong tone indicated that the corresponding opinion holds significant importance. Moreover, following each theme extraction, the outcomes of the mentioned above two forms of analysis were immediately returned to each research participant for verification and validation.
Rigor and trustworthiness
In order to ensure the credibility, reliability, generalizability, and repeatability of the study, a series of measures were taken during the research process. Before the interviews, the researcher thoroughly reviewed the theoretical knowledge relevant to the interview topic through literature research and consultations with experts. This was done to ensure an accurate comprehension of the interviewees’ accounts. Secondly, to maximize the sample’s ability to reflect various situations of the research subjects, maximum variation sampling was employed. During the interviews, The interviewer always maintained a neutral attitude without making a judgment, and audio recordings were made throughout. The audio was transcribed verbatim within 48 h after the interviews concluded and then underwent a second-round verification. Moreover, to reduce research biases and promote the researchers’ self-reflection, the research team regularly discussed the rationality of coding, the degree of theme matching, etc., and made corresponding modifications based on the discussion results.
Results
Sample description
A total of 14 diabetic patients, 8 males and 6 females, with an age range of 23 to 56 years, a median of 32 (IQR 23–40) years, a disease duration range of 1 to 120 months, a median of 6 (IQR 2–45) months, and an education level of junior high school to bachelor’s degree, were interviewed in this study. Table 2 displays the participants’ characteristics, and Table 3 briefly describes each participant.
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Table 2
Participants’ characteristics (N = 14)
Characteristics | Values, n (%) |
|---|---|
Gender | |
Male | 8 (57) |
Female | 6 (43) |
Age (years) | |
20–29 | 3 (21) |
30–39 | 8 (57) |
40–49 | 2 (14) |
50–59 | 1 (7) |
Marital status | |
Single | 2 (14) |
Married | 11 (79) |
Divorced | 1 (7) |
Education | |
Secondary school | 1 (7) |
Vocational secondary school/High school | 4 (29) |
Post-secondary/Bachelor’s degree | 9 (64) |
Occupational status | |
Employed | 6 (43) |
Unemployed | 6 (43) |
Self-employed | 2 (14) |
Residence | |
Urban | 12 (86) |
Rural | 2 (14) |
Type of disease | |
T1DM | 3 (21) |
T2DM | 8 (57) |
GDM | 3 (21) |
Medical insurance | |
Urban employee medical insurance | 6 (43) |
Urban resident medical insurance | 8 (57) |
Disease duration (years) | |
< 3 | 10 (71) |
3–5 | 1 (7) |
> 5 | 3 (21) |
Number of complications | |
0 | 11 (79) |
1 | 2 (14) |
≧ 2 | 1 (7) |
Treatment program | |
Oral hypoglycemic drug | 3 (21) |
Insulin injection | 10 (71) |
Oral hypoglycemic drugs combined with insulin | 1 (7) |
Ways to learn about services | |
Recommendations from relatives or friends | 2 (14) |
WeChat Public | 4 (29) |
Search via the Internet | 8 (57) |
Table 3
Individual participant descriptions
ID | Education | Occupational status | Type of disease | Disease duration (months) | Complication | Treatment program |
|---|---|---|---|---|---|---|
P1 | Secondary school | Employed | T2DM | 72 | 2 | Oral hypoglycemic drugs combined with insulin |
P2 | High school | Unemployed | T1DM | 6 | 0 | Insulin injection |
P3 | Bachelor’s degree | Employed | T2DM | 6 | 0 | Oral hypoglycemic drug |
P4 | Bachelor’s degree | Employed | T2DM | 120 | 1 | Insulin injection |
P5 | High school | Unemployed | GDM | 8 | 0 | Insulin injection |
P6 | Post-secondary | Self-employed | T1DM | 12 | 0 | Insulin injection |
P7 | Bachelor’s degree | Employed | T2DM | 1 | 0 | Oral hypoglycemic drug |
P8 | Post-secondary | Employed | T2DM | 36 | 1 | Insulin injection |
P9 | Bachelor’s degree | Employed | T1DM | 2 | 0 | Insulin injection |
P10 | Post-secondary | Self-employed | T2DM | 1 | 0 | Insulin injection |
P11 | Vocational secondary school | Unemployed | GDM | 4 | 0 | Insulin injection |
P12 | Bachelor’s degree | Unemployed | GDM | 1 | 0 | Insulin injection |
P13 | Vocational secondary school | Unemployed | T2DM | 120 | 0 | Oral hypoglycemic drug |
P14 | Post-secondary | Unemployed | T2DM | 5 | 0 | Insulin injection |
Diabetics’ experiences of Internet-based nursing clinic services
Four themes were extracted from the interview data: content and effectiveness of Internet-based nursing clinic services, nurses’ service attitude and level, timeliness of services, and service platform design.
Theme 1: Content and perceived effectiveness of Internet-based nursing clinic services
Most of the interviewees recognized the content and effectiveness of the INCS. Some patients believed they could obtain one-on-one health consultation services and personalized care plans through these services.
It is good that the caregivers who provide the service can give me specific advice on the issues I have raised and let me know the specific care methods. [P1]
Some patients used the Internet-based nursing clinic to consult on matters and processes related to offline medical care, which facilitated offline medical care.
Because I suddenly found out that I had diabetes while I was working outside, and then I planned to come over here to be hospitalized. I consulted on the internet about what tests I should have done before I was hospitalized and what the specific process was like… This way, I could prepare in advance and save time. [P7]
Patients also reported that by consulting the Internet-based nursing clinic services, they improved their understanding of health issues, thus relieving their anxiety and tension.
By online consultation, that nurse told me what was going on and what to do, that way, I probably had a clear idea in my mind, and my anxiety was relieved to a certain extent. [P11]
There were also patients in the interviewees who did not recognize the effectiveness of Internet-based nursing clinic services. Some patients thought that they could not communicate with nurses face-to-face and were worried that this would affect the efficacy of the treatment.
Generally speaking, if we consult online, we just use it for a reference. After all, some suggestions are not too assured … Because there is no site to do all the tests, there is no specific standard. [P3]
Theme 2: Nurses’ service attitude and level
Most patients believed that the caregiver who provided the Internet-based nursing services was patient, responded carefully, had a good attitude, and her ways of expression were also easy to be accepted.
The attitude was perfect, and the response was careful. [P1]I think she gave me a reply that I could understand, and it was relatively easy for me to comprehend. [P5]
However, some patients reported that the nurse’s responses were not based on their actual needs; they felt perfunctory and that the patient experience was not good.
I shouldn’t have chosen her to continue with the consultation because I mainly wanted to find out if there was any suitable medication available, but her response was not what I wanted to get, and it was a perfunctory answer. [P6]
Theme 3: Timeliness of services
Patients who used the graphic counseling service indicated that they were waiting for the nurse to respond for a long time and the reply was not very timely.
The responses are a bit slow. Sometimes, when you’re in a hurry and ask for a consultation there, it can take half an hour to get a reply. [P5]
It feels like they don’t specialize online; it feels like she only responds when she has time and doesn’t respond when she doesn’t have time. [P7]
Theme 4: Design of the service platform
Some patients said that the process of using the Internet-based nursing clinic services platform is relatively smooth and the operation is relatively simple.
The design is still relatively popular. It looks relatively simple and intuitive, and the navigation is also relatively intuitive and simple, not complicated. [P13]
However, some patients also said that the design of the service platform is unreasonable.
The design is a little unreasonable. When the nurse replies to my message, there is no hint on WeChat, and I need to click on the consulting interface again to check whether the nurse has replied. [P7]
Factors influencing the adoption behavior of Internet-based nursing clinic services for diabetic patients
Based on the HITAM model, four factors influencing the adoption behavior of Internet-based nursing clinic services for diabetic patients were finally extracted by the directed content analysis method, including health status, perceived usefulness, perceived ease of use, and subjective norm. In addition, content that did not involve concepts related to the HITAM model was analyzed using traditional content analysis, and one factor was extracted, namely social influences, which contained three sub-themes (Table 4).
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Table 4
Factors influencing the adoption behavior of Internet-based nursing clinic services for diabetic patients
Factor | Theme | Sub-theme |
|---|---|---|
Within the HITAM model | Health status | - |
Perceived usefulness | - | |
Perceived ease of use | - | |
Subjective norm | - | |
Outside the HITAM model | Social influences | Internet development trends |
Epidemic of COVID-19 | ||
Difficulty in accessing medical care offline |
Health status
Internet-based nursing clinic services were chosen when patients perceived their illness as not serious or when people around them had corresponding health problems.
If the situation is urgent, I might go straight to the hospital, and if I feel like I can still slow down a little bit, I would ask for a consultation online first. [P2]
Perceived usefulness
Most patients can access personalized care plans from Internet-based nursing clinic services, which also clarify the offline process and facilitate the patient’s access to care. When patients perceived the Internet-based nursing clinic services as applicable, they chose to use them.
I think it’s still very convenient, as we patients are home alone. Some small problems can be solved by communicating with online professionals through this platform, and it’s easy to use, so I will use it. [P2]
Perceived ease of use
Patients reported that the ease of operation of the Internet-based nursing clinic platform and the ease of access to health services were able to promote their use of the service.
The platform is designed to be simple and convenient, and I will continue using it. [P10]
Subjective norm
Patients indicated that recommendations from family, friends, and medical staff influenced their use of the service, with medical staff having the most significant influence.
If a friend or family member close to me or just like your nurse recommends it to us, I will probably keep using it. [P13]
Internet development trends
As an emerging nursing service model in the context of Internet healthcare, Internet-based nursing clinic services have brought great convenience to patients seeking medical treatment. They are increasingly becoming another new way for people to seek healthcare services. Patients say this is the development trend of the times and will inevitably be used in the future.
I think online consultation will become increasingly popular in the future, and when people accept this service model, they will not need to come to the hospital. [P10]
Epidemic of COVID-19
The emergence of Internet-based nursing clinic services can provide health services to diabetic patients who are susceptible and high-risk groups for COVID-19. Patients chose to consult online because, on the one hand, they were quarantined at home and had no other means of access to health care due to the epidemic control; on the other hand, they were afraid of contracting COVID-19.
At that time, because of the epidemic prevention and control, we could not go to the hospital directly, and then we could only consult online. [P11]
Difficulty in accessing medical care offline
The respondents mentioned that the reason for choosing online consultation is the scarcity of offline appointments and the difficulty in seeking medical treatment offline.
In the case of large hospitals, it’s difficult to get an appointment, and then you have to queue up after arriving, which is too troublesome. [P6]
Suggestions from people with diabetes for improving the quality of Internet-based nursing clinic services
Enriching service channels and improving platform functions
The current Internet-based nursing clinic services only open two forms of service: graphic consultation and video consultation. Patients suggested adding telephone consultation services for patients with lower literacy levels and older age. Another patient hoped that the Internet consultation platform would add a rapid triage module to solve the difficulty of registering.
Sometimes, I want to communicate directly with the nurse on the phone. I don’t recommend image and text consultation because many patients, such as the uneducated, the rural residents, and the older ones, don’t know how to consult with pictures and text. For online consultation, I think image and text consultation can’t be the main kind of way, it’s better to add a telephone consultation, this kind is the best. [P10]This platform could take a cue from ‘Ping An Doctor’ and add a quick consultation feature. After describing all symptoms, there would be a quick triage module that tells you which department you should actually go to. This would also make it easier for patients to quickly and accurately find the appropriate department.[P8].
Fixed reception hours to improve service efficiency
Through interviews, it was found that patients using the image and text consultation service of Internet-based nursing clinics expressed that the response speed of the service is slow. They hope that nurses can improve the speed of receiving patients, set specific service times, and respond to patient information in a timely manner to enhance service efficiency.
I think… couldn’t we set aside a certain amount of time each day specifically for online work, so as to ensure the continuity of communication? [P7]
My suggestion is whether some nurses can provide services within a set period. Within that period, they will be dedicated to online services to ensure they can promptly respond to patient information and improve service efficiency. [P10]
Discussion
This study was the first study using a qualitative research approach based on the HITAM to investigate the needs and experiences of Chinese diabetics using INCS. We found that diabetics had both positive and negative experiences with the services. Four factors impacting patients’ adoption behavior of INCS were compatible with the model and one was not. These findings will be expected to optimize and promote local INCS to some extent.
Satisfaction with the service’s content and effect was the primary indicator of the patients’positive service experiences. Patients had better experiences when nurses offered more extensive service content [25]. The design of the service platform, nurses’ service attitude and level, and service content were all important elements influencing patient experience [26]. In this study, a similar result was found. Nonetheless, several patients also mentioned that some nurses didn’t communicate well enough. They either gave casual answers or couldn’t adequately address the requirements of the patients. One possible explanation is that nurses have not yet gotten used to the online consultation service, which does not require face-to-face interaction. A negative patient experience results from their inability to accurately assess patients’ emotional reactions, which makes it challenging to give prompt and precise feedback [27]. Therefore, before the nurses treat patients online, they must complete adaptive training. Nurses can develop their communication skills by interacting with patients in different emotional states and communication styles through the simulation of online service scenarios. Case studies on nonverbal signs including text tone, emoticons, and response intervals should be carried out. Additionally, patients’ experiences with online consultation services were significantly impacted by timeliness of service [28]. Nurses in our study were only able to offer online consultation services during their off-duty hours, which prevented them from giving prompt feedback. As a result, nursing administrators should allow qualified nurses to have specific time to offer effective medical consultations online.
This study also determined the elements that affect the adoption of INCS by diabetic patients. These primarily comprised health status, perceived usefulness, perceived ease of use, subjective norm, and social influences. Firstly, adoption behavior only happened when the demand for service was high, and the patient’s health state might be an important influencing factor. According to Andersen’s Behavioral Model of Health Services Use, the primary motivator behind a person’s decision to use health services is need [29]. As noted by the Health Belief Model [30] and the Protection Motivation Theory [31], an individual’s health behaviors may be influenced by their perception of the severity of their sickness. In our study, we also discovered that patients chose to utilize INCS only when their illnesses were not severe.
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Perceived usefulness refers to how much patients can benefit themselves by using INCS. This study discovered that patients’ willingness to accept INCS was increased by perceived usefulness. A related research also found that it had a considerable impact on users’ satisfaction with online clinic services, which in turn influenced their willingness to use it [32]. However, because they couldn’t see nurses in person, people were worried about how effective online services were. For instance, nurses might not have access to their particular medical records or be allowed to do certain tests on them according to rating criteria. A prior study also discovered that elderly patients believed the quality of telehealthcare services was inferior to in-person consultations when physical examinations were not conducted during online consultations [33]. Although this was a natural drawback of online medical consultation services, patients’ worry could be effectively allayed by offering them detailed self-examination techniques through more thorough questions or video consultations.
Perceived ease of use refers to the degree to which patients believe INCS is easy to use. This study found that patients chose INCS platforms because of its ease of operation and convenience in accessing health services. Another study also found that stroke patients were more likely to use telemedicine services because the virtual clinic platform was easy to use [34]. However, the respondents in this study were young and middle-aged, with higher levels of self-efficacy and literacy, and therefore more likely to access new technologies. In contrast, older diabetics may require more time and effort to get over the challenges when they utilize the platform, due to declining physical health and cognitive function. Consequently, healthcare institutions ought to provide individualized consultation channels, including telephone consultation service, or combine it with text and visual consulting. The patient port’s operation interface and procedure should be made more user-friendly and simplified [35]. In addition, AI has been applied to the service platform, which helps patients quickly find a nurse qualified to offer counseling services [36].
Furthermore, important individuals in the diabetics’ lives (friends, family, and medical professionals) also had an impact on their adopting behavior toward INCS. Healthcare professionals were the most influential among them, which is in line with other researches. For instance, a mixed-method study discovered that patients’ intention to use telemedicine might be determined by the advice of medical professionals [37]. Patients with intestinal stomas were more likely to accept Internet-based diagnosis and treatment services when they received recommendations from medical professionals [38]. The possible reason is that patients have greater faith in medical personnels’ competence and authority. So medical professionals should be the most important propagandists of INCS, and the patients’ close friends or family should also be the target audience other than the patients.
The Internet development trends, the epidemic of COVID-19, and the challenge of obtaining offline medical treatment were the primary societal influence elements. Internet-based healthcare services have become a new development trend with the implementation of national strategies such as “Internet +” and “Healthy China”, as well as the ongoing expansion of health system reforms [39]. The public’s awareness and acceptance of the service can be greatly increased by the government’s active support and assistance. Official mainstream media and new media could be a good way to introduce INCS’s consultation guidelines and service scope to the public. And the medical institutions may provide some free online consultations at the appropriate time for patients who are not familiar with INCS. Our study found that INCS was more popular during the period of COVID-19, which was in line with a prior study [40]. Additionally, patients were more likely to use INCS when offline medical access was more challenging, such as difficult-to-get appointments, lengthy lines, and lengthy wait times. The same result was also found in another study on patients’ utilization of “Internet +” Chinese medicine services. Therefore, more convenient, timely, and patient-centered INCS should be provided, so as to leverage its greatest strengths and benefit more people [41].
Limitations
First of all, the research subjects in this study were mainly from a particular region in Anhui Province, China, and the results of this study were specific due to the differences in the level of economic development, service organizations, and service levels in each region. Researchers in other regions need to incorporate local patient experiences in order to obtain strategies for improving the quality of local Internet-based nursing clinic services. Secondly, during the implementation of this study, patients were required to recall the process of receiving INCS, which may lead to recall bias. In the future, efforts should be made to recruit interview subjects as soon as possible after the patient consultation ends, to ensure the reliability of the research results. Finally, this study was descriptive qualitative research, and the representativeness and generalizability of the findings are limited. Future research could consider conducting quantitative studies based on the results of this study, constructing predictive models for the intention or behavior of diabetic patients to adopt INCS, and exploring the magnitude of the effects of various influencing factors and the path relationships between them, laying the foundation for interventional studies.
Conclusions
This study, guided by the Health Information Technology Acceptance Model, explored diabetic patients’ experience of INCS. The findings indicated that diabetic patients had a positive experience with the content and effect of INCS, nurses’ service attitude and level, and service timeliness on the whole. They perceived that INCS contributed to their health management and provided certain assistance and support. However, there were also negative experiences, such as concerns about the effectiveness of treatment and services not being timely enough. Factors affecting diabetic patients’ utilization of INCS include health status, perceived usefulness, perceived ease of use, subjective norm, and social influences. It is recommended that medical institutions should increase the publicity and promotion of INCS, pay attention to the subjective normative role of medical personnel, and enhance the perceived usefulness of service for patients. At the same time, they can also improve the function of the service platform, enhance the aging design, and improve the ease of use of the platform to promote the use of patients.
Acknowledgements
We’d like to thank everyone who participated in the survey.
Declarations
Ethics approval and consent to participate
The Anhui Medical University Ethics Committee (Ethics No. 2021H036) reviewed this study, which adhered to the Declaration of Helsinki. Ethical considerations were prioritized throughout the research, and voluntary participation and confidentiality principles were strictly upheld. We consistently focused on protecting the interviewees’ privacy and respecting their right to informed consent. Informed consent was obtained from all participants prior to the interviews.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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