Acceptance of the Internet-Based Sharing Nursing Service among caregivers of elderly with chronic diseases

China had 264 million people aged 60 and above in 2020, accounting for 18.70% of the country’s total population [1]. The proportion of elderly with at least one chronic disease was as high as 75% in 2019. It is usually time consuming and inconvenient for the elderly to access to hospitals. Traditionally, community nurses undertake the responsibility of providing home visits in China; however, they often fail to fulfill this responsibility due to serious staffing shortage, low work morale and failure of public trust [2]. In addition, community nurses, compared to nurses working in hospitals, especially tier-three hospitals, are with less training and thus low level of professional competency [3].

The imbalance of need and supply drew attention from policymakers. The National Health Commission issued a notice on piloting the “Internet Plus Nursing Service”, also known as the “Internet-Based Sharing Nursing Service” (IBSNS) in six provinces and municipalities in 2019 [4] and another notice on upscaling the IBSNS in 2020 [5]. IBSNS refers to the nursing services provided by nurses at patients’ homes relying on Internet technology. People first need to apply for IBSNS on the IBSNS platforms (most known as web-based mobile apps and some are WeChat mini programs), and then nurses accept orders and visit patients’ homes to provide corresponding IBSNS, generally including routine nursing operations such as intramuscular injections, and specialty care such as urethral catheterization [6]. IBSNS is expected to improve allocation and utilization of health care resources by providing nursing services for clients at their homes [4, 7]. It is also expected to ease family’s pressure to care for elderly family members [7]. At the same time, IBSNS offers nurses a chance to earn extra income and provide opportunities of flexible work schedules [8].

Although IBSNS has many advantages and is strongly encouraged by the government, the usage of IBSNS is not optimistic. A study showed that the total number of downloads of seven IBSNS apps were less than 25,000, and two of them were only downloaded 2614 and 3547 times [6]. It was reported that the average numbers of clients ordering IBSNS were only 104, 1,858 and 858 times a year for the three IBSNS platforms localized in Wuhan, Nanjing and Shenzhen, respectively [9‐11]. Several studies have investigated from the user’s perspective to understand the reasons for the IBSNS underutilization. Behavioral intention, which is phrased as “the extent to which an individual intends to use a technology” [12], becomes a research focus. A pilot survey among patients with chronic diseases found that 52% of the participants were reluctant to utilize IBSNS [13]. Another two studies among community residents reported a moderate level of behavioral intention to use IBSNS [14, 15]. It has been reported that being younger, with lower education, worse economic status, being divorced or widowed, without health insurance, and without chronic diseases are associated with lower level of acceptance of IBSNS [14‐16].

The Technology Acceptance Model (TAM) provides a useful theoretical framework to understand antecedents of behavioral intention of technology use, which was developed by Davis [17], and has been used in health service systems to explore the factors associated with the acceptance of information technology [18, 19]. The TAM postulates that behavioral intention is determined by perceived usefulness and attitude towards new technologies, and the latter depends on perceived usefulness and perceived ease of use [12]. TAM also points out that improvements in perceived ease of use can contribute to increased perceived usefulness [12]. Perceived usefulness is defined as “the degree to which a person trusts that using a particular system would increase his/her job performance” (p. 320), while perceived ease of use refers to “the subjective perception of whether a particular system would be free of effort to use” (p. 320) [20].

It should be noted that the TAM is limited by leaving out some importance variables, such as perceived security, which has been reported a major concern for both nurses and users [21]. Perceived security is defined as “the degree to which one believes that security is guaranteed when using new technologies”, and was regarded as a critical construct that explains users’ attitude towards newly developed technological products [22, 23]. Therefore, we modified the TAM by including perceived security as an explaining variable linking to attitude.

Some researchers have explored the associated factors of acceptance of IBSNS based on the TAM. For example, Jiang et al. [24] found that perceived usefulness was significantly associated with attitude to use IBSNS and attitude was significantly associated with behavioral intention to use IBSNS among patients who visited a tier-three hospital. Xie et al. [25] found that perceived ease of use was positively associated with perceived usefulness of IBSNS and the latter was further positively associated with the intention to continue using IBSNS among Chinese elderly users. However, there is a lack of studies examining the associated factors of acceptance of IBSNS among caregivers of elderly with chronic diseases based on the TAM, who are often the actually users of IBSNS as they are often the person that arranges care services for their elderly family members [10].

This study aimed to explore the acceptance of IBSNS by caregivers of elderly with chronic diseases and related factors based on the modified TAM (mTAM) (Fig. 1). Specifically, our research questions were: (1) Are perceived usefulness, perceived ease of use and perceived security positively associated with attitude toward IBSNS? (2) Are perceived ease of use positively associated with perceived usefulness of IBSNS? (3) Are perceived usefulness and attitude positively associated with behavioral intention to use IBSNS?

Based on the mTAM, this study explored the acceptance of ISBNS among caregivers of elderly with chronic diseases. A greater part of participants had moderate to weakly positive behavioral intention to use IBSNS in this study, which was slightly higher than community residents and patients (most were non-chronic patients) [14, 24]. This may be because caregivers of elderly with chronic diseases are often the potential users of IBSNS for arranging home-based nursing services for elder people with chronic conditions, and therefore, they demonstrated higher demand for IBSNS. Even only recruited participants from the capital city of China and the participants were relatively well-educated, the acceptance level in this study remained informative, because most of the IBSNS platform apps only covered first-tier cities [6].

The finding that attitude was positively directly associated with behavioral intention of using IBSNS was consistent with other studies on nascent medical technologies, for example, the smart hospital services [29] and electronic healthcare record systems [30]. Positive attitude implies a good notion of something and can therefore increase individuals’ intention to employ it [29].

Perceived usefulness was another modifiable factor associated with higher behavioral intention of using IBSNS not only indirectly through attitude, but also directly, which was consistent with research on health-related Internet use [31]. On the one hand, people’s perception that a method can improve outcomes increases their affect towards the method [32]. On the other hand, people form intentions for behaviors that help them live, work, and solve real problems based on not only their positive or negative feelings, but also the usefulness of these the measures [12]. Therefore, improving caregivers’ acceptance of IBSNS can be approached by fostering their positive attitudes and increasing perceived usefulness toward IBSNS.

Previous studies consistently found significant relationship between perceived security and attitude towards new tech products [22, 23, 30]. A possible explanation is that when people perceive potential risks associated with new technology or technology based services, their trust in the service compromised, which in turn leads to negative attitudes toward the service [30]. For the IBSNS, it suffers from security threats that all Internet-based services commonly face, such as threats of personal information leaking and privacy violation, as well as healthcare-related security risks, such as malpractice, adverse events of medications or treatments, and nurses’ personal security [21, 33]. This suggests that a review of IBSNS security issues is important. Addressing security problems can foster a favorable attitude towards IBSNS among caregivers, thereby improving acceptance.

As the most upstream predictor in the mTAM, high level of perceived ease of use was associated with high level of perceived usefulness, which was consistent with previous reports [29, 34]. Users value the ease of use of new technology when they form the perception of usefulness [35]. Ease of use is the first point people pay attention to a new product when they encounter one, and the higher the perceived ease of use, the stronger their willingness to actively learn about the product, and thus discovering the usefulness [35, 36]. Therefore, improving the ease of use of IBSNS, especially the IBSNS apps, can motivate caregivers to continue exploring and uncover the usefulness of IBSNS, ultimately increasing their acceptance levels.

Different studies involving the association between perceived ease of use and attitude had inconsistent results. Some studies suggested that perceived ease of use was directly associated with attitude [31, 37], whereas consistent with our findings, two studies did not find significant relationship between perceived ease of use and attitude towards clinical practice guidelines on antimicrobial [22] and electronic health care records [30]. This insignificant result may be because the participants in our study were relatively young and highly educated, and therefore, they might be very proficient in technology use, which does not necessarily relate to positive attitude directly [30, 37].

This study has several limitations. First, we recruited participants using convenience sampling from Beijing only, which makes the sample not nationally representative. The participants in this study were relatively well educated and had high income. Further studies among more representative samples are warranted. Second, the cross-sectional research design limits the ability to examine long-term acceptance of IBSNS among caregivers, and further longitudinal studies are needed. Third, the study did not distinguish between those who had used IBSNS and those had not. Venkatesh & Bala [35] suggest that experience with a system can moderate the effect of perceived ease of use on behavioral intention and perceived usefulness of the system. We only controlled for this possible influence by including the experience with IBSNS as a covariate because the numbers of caregivers who had used IBSNS were too small to conduct a moderator analysis in this study. Future studies could examine the role of experience and other caregiver characteristics in the caregivers’ acceptance of IBSNS. Fourth, although we improved the comprehensiveness of the TAM by adding the perceived security to the model, there might be other constructs that affecting acceptance that left out in the model, such as technology features, self-efficacy, and habit [19]. The TAM model can be further extended in the future. Finally, this quantitative research is limited in its ability to gain a deeper understanding of the caregivers’ lived experience and perceptions of IBSNS, which needs be studied using qualitative methodology in future.

The findings provide some implications. The acceptance level in this study was moderate to weakly positive, and the acceptance of IBSNS may be even lower in other disadvantaged populations [16‐18]. This is of practical implication that IBSNS is not well accepted by potential users. Efforts should be made to enhance the acceptance among these groups. First, this study suggests that perceived security related to the acceptance of the IBSNS. However, a survey found that the credentials of some IBSNS practicing entities did not meet the regulation of collaborating with entity medical institutions [38], and there is still lack of regulation of IBSNS which places IBSNS at high security risk. Therefore, further oversight and regulation of the IBSNS were suggested. For instance, policymakers could take the initiative in establishing a supervision agency and refine vetting processes to ensure security of IBSNS. Healthcare providers can educate caregivers with these measures to improve caregivers’ perception of security of IBSNS. Second, increasing the usefulness of IBSNS by enriching types of home-based nursing services and increasing service quality can be helpful for improving acceptance. Studies showed that the current IBSNS apps only provided a limited number of home-based nursing services [6] and the service quality needed to be improved [39]. Healthcare providers can investigate types of home-based nursing services in need, expectations of quality, and barriers, facilitators and measures of quality improvement. For example, healthcare originations can form quality supervision team to collect clients’ feedback, promptly identify issues related to service quality, and formulate improvement plans. Additionally, they can provide relevant training to nurses to enhance their core competences. Third, increasing awareness of IBSNS and perceived ease of use is beneficial for improving the acceptance. Nurses can disseminate IBSNS among patients and caregivers to raise awareness. They can also work with IBSNS platform developers to improve user interface and enhance user experience services, as well as work with other professionals such as social workers to increase public digital literacy. Furthermore, the study findings are also informative to countries that are looking to implement similar technological advancements in their healthcare systems.

Guided by the mTAM, this study explored the acceptance of IBSNS among a sample of Chinese caregivers of elderly with chronic diseases. We found that the level of behavioral intention to use IBSNS was moderate to weakly positive, and behavioral intention was associated with attitude and perceived usefulness. Perceived usefulness and security were drivers of attitude towards IBSNS, and perceived usefulness may be determined by perceived ease of use to some extent. Improving the ease of use, security, and usefulness may be helpful to increase the positive attitude towards IBSNS and behavioral intention of using IBSNS. The study findings are important for improving IBSNS and informative to countries that are looking to implement similar technological advancements in their healthcare systems.