The Open Nursing Journal




ISSN: 1874-4346 ― Volume 14, 2020
RESEARCH ARTICLE

Issues Related to the use of a Mobile Application of the Protocol for Preventing and Managing Urinary Catheter Blockage Among Long-term Indwelling Urinary Catheter Users for Visiting Nurses: An Interview Study of Visiting Nurses in Japan



Moriyoshi Fukuda1, *, Shuko Maeda1, Takako Takiuti1, Manabu T. Moriyama2
1 Department of Nursing Science, Kanazawa Medical University, Uchinada, Japan
2 Department of Urology, Himi Municipal Hospital, Kanazawa Medical, Toyama, Japan

Abstract

Background:

We developed a mobile application of the protocol for preventing and managing catheter blockage among long-term indwelling catheter users for visiting nurses. We conducted meetings at four visiting nurse stations in Japan from May to June 2017 to explain the application to visiting nurses.

Objective:

The purpose of the present study was to clarify issues related to the full-scale use of this protocol application, using data from focus group interviews with visiting nurses.

Methods:

We conducted focus group interviews with the meeting participants. The focus group interviews were conducted at four different venues. Three focus groups had eight participants, and the fourth had two participants, for a total of 26 study participants. Specifically, the group interviews covered (1) the application’s structure and content; (2) operability; (3) portability; (4) possibilities for use, effects, and expectations; and (5) concerns about use.

Results:

The results of the group interviews were classified into five categories: possibilities for the use of the mobile application, possibilities for further use of the application by nurses, suggestions for the use of the application by caregivers and nursing care workers, the burden associated with the use of the mobile application, and opinions and desires for improvements in the mobile application.

Conclusion:

The results suggested that visiting nurses would use the mobile application. However, for full-scale use, it would be necessary to add the ability to use accumulated data, increase the number of learning screens, and take safety management measures for the transmission of medical information.

Keywords: Visiting nurse, Urinary catheterization, Catheter blockage, Protocol, Mobile application, Information and communication technology, Urinary tract Infection.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 100
Last Page: 108
Publisher Id: TONURSJ-14-100
DOI: 10.2174/1874434602014010100

Article History:

Received Date: 13/12/2019
Revision Received Date: 02/05/2020
Acceptance Date: 07/05/2020
Electronic publication date: 21/06/2020
Collection year: 2020

© 2020 Fukuda et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Nursing Science, Kanazawa Medical University, 1-1 Daigaku, Uchinada, 920-0292, Japan; Tel: +81-76-286-2211, ext: 7595; E-mail: m-fukuda@kanazawa-med.ac.jp





1. INTRODUCTION

The indwelling duration is prolonged in patients with indwelling catheters (hereafter referred to as catheters) living at home, which can result in complications such as urinary tract infection or catheter blockage [1Maeda S, Takiuti T, Komatsu T, et al. Current status of long-term indwelling urinary catheter management by visiting nurses. Int J Urol Nurs 2013; 7(2): 76-84.
[http://dx.doi.org/10.1111/ijun.12001]
, 2Wilde MH, McDonald MV, Brasch J, et al. Long-term urinary catheter users self-care practices and problems. J Clin Nurs 2013; 22(3-4): 356-67.
[http://dx.doi.org/10.1111/jocn.12042] [PMID: 23301577]
]. In particular, catheter blockage has been reported to require emergency care by visiting nurses, emergency outpatient services, or hospitalization [3Maeda S, Takiuti T, Komatsu T, et al. Current status of long-term indwelling urinary catheter emergency management by visiting nurses. HOUMONKANGO TO KAIGO 2012; 7(9): 888-92. [in Japanese]., 4Maeda S, Takiuti T, Kohno Y, et al. Catheter blockage factors in patients cared for in their own home requiring long-term urinary catheterization. Int J Urol Nurs 2017; 11(1): 52-9.
[http://dx.doi.org/10.1111/ijun.12123]
]. Medical expenses caused by catheter blockage are reportedly increasing [2Wilde MH, McDonald MV, Brasch J, et al. Long-term urinary catheter users self-care practices and problems. J Clin Nurs 2013; 22(3-4): 356-67.
[http://dx.doi.org/10.1111/jocn.12042] [PMID: 23301577]
]. In fact, approximately half of visiting nursing service users with catheters who live at home have been reported to develop catheter blockages within 6 months, and half of these patients experience repeated catheter blockages [4Maeda S, Takiuti T, Kohno Y, et al. Catheter blockage factors in patients cared for in their own home requiring long-term urinary catheterization. Int J Urol Nurs 2017; 11(1): 52-9.
[http://dx.doi.org/10.1111/ijun.12123]
]. Catheter blockage may disturb the urinary flow and increase the pressure in the bladder, which may cause pyelonephritis and sepsis. Catheter blockage is induced by parenchymal conditions such as formations of biofilm or other deposits accumulating in the catheter or by the torsion and compression of the catheter [5Stickler DJ, Morgan SD. Observations on the development of the crystalline bacterial biofilms that encrust and block Foley catheters. J Hosp Infect 2008; 69(4): 350-60.
[http://dx.doi.org/10.1016/j.jhin.2008.04.031] [PMID: 18550219]
]. The characteristics of patients who are prone to catheter blockage include a large amount of sediment in the urine, leakage of urine around the catheter, and female sex [6Wilde MH, McMahon JM, Crean HF, Brasch J. Exploring relationships of catheter-associated urinary tract infection and blockage in people with long-term indwelling urinary catheters. J Clin Nurs 2017; 26(17-18): 2558-71.
[http://dx.doi.org/10.1111/jocn.13626] [PMID: 27805758]
].

A checklist for the prevention of catheter blockage has been developed to encourage patients with spinal cord injuries to perform self-management [7Queensland Spinal Cord Injuries Service. Preventing catheter blockages: a guide for health professionals 2019. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/427508/catheter-blockage.pdf]. However, this checklist was not designed to assess the risk or occurrence of catheter blockage. Therefore, considering that visiting nurses are tasked with preventing catheter blockage, assessing the presence or absence of blockages, and coping with blockages during home visits, we developed a protocol for preventing and dealing with catheter blockage among long-term indwelling catheter users for visiting nurses (henceforth referred to as “the protocol”), which consists of three sub-protocols: (1) a protocol for identifying the factors of catheter blockage; (2) a protocol for assessing catheter blockage; and (3) a protocol for dealing with catheter blockage.

We conducted a pilot study of the protocol involving visiting nurses and catheter users. The results revealed that the protocol caused errors in the observation route and order [8Maeda S, Takiuti T, Manabu T. Development of “the visiting nurse urinary monitoring protocol”-visualization of the working (in Japanese). HOUMONKANGO TO KAIGO 2017; 22(6): 484-90.]. Thus, we considered it necessary to develop a mobile application of this protocol using information and communication technology, such as personal computers and tablets, to automatically guide the observation route and order. We, therefore, developed a mobile protocol application.

The use of applications has been shown to be effective for managing patients’ symptoms and for other aspects of outpatient management [9Egawa M, Okamoto K, Nishimura F, et al. Development of a smartphone application system of symptom-recording to manage premenstrual syndrome and its clinical use. J Japanese Soc of Psychosom Obstetrics and Gynecol 2015; 21(1): 105-13., 10Kho SES, Lim SG, Hoi WH, Ng PL, Tan L, Kowitlawakul Y. The development of a diabetes application for patients with poorly controlled type 2 diabetes mellitus. Comput Inform Nurs 2019; 37(2): 99-106.
[http://dx.doi.org/10.1097/CIN.0000000000000485] [PMID: 30407213]
]. It has also been reported that the use of learning applications for nursing techniques is effective for improving the knowledge, skills, and self-efficiency of nursing students [11Lall P, Rees R, Law GCY, Dunleavy G, Cotič Ž, Car J. Influences on the implementation of mobile learning for medical and nursing education: qualitative systematic review by the Digital Health Education Collaboration. J Med Internet Res 2019; 21(2): e12895.
[http://dx.doi.org/10.2196/12895] [PMID: 30816847]
, 12Kim H, Suh EE. The effects of an interactive nursing skills mobile application on nursing students’ knowledge, self-efficacy, and skills performance: a randomized controlled trial. Asian Nurs Res (Korean Soc Nurs Sci) 2018; 12(1): 17-25.
[http://dx.doi.org/10.1016/j.anr.2018.01.001] [PMID: 29463484]
]. Nurses have been found to use applications to build networks with members of other professions (cited), to solve nursing problems [13Yang Y, Bass EJ, Bowles KH, Sockolow PS. Impact of home care admission nurses’ goals on electronic health record documentation strategies at the point of care. Comput Inform Nurs 2019; 37(1): 39-46.
[http://dx.doi.org/10.1097/CIN.0000000000000468] [PMID: 30074919]
], and as learning support tools. The number of reports has been increasing each year [14Chang C-Y, Lai C-L, Hwang G-J. Trends and research issues of mobile learning studies in nursing education: A review of academic publications from 1971 to 2016. Comput Educ 2018; 1116(C): 28-48.
[http://dx.doi.org/10.1016/j.compedu.2017.09.001]
]. Applications for nurses have been developed in many areas and are expected to be increasingly used in nursing care settings in the future. Applications for catheter management have previously been developed for ward nurses, including the Automated Risk Assessment System [15Hur EY, Jin Y, Jin T, Lee SM. Development and evaluation of the automated risk assessment system for catheter-associated urinary tract infection. Comput Inform Nurs 2019; 37(9): 463-72.
[http://dx.doi.org/10.1097/CIN.0000000000000506] [PMID: 30807296]
], and for those assisting patients with catheter-associated urinary tract infection [16Schnall R, Iribarren SJ. Review and analysis of existing mobile phone applications for health care-associated infection prevention. Am J Infect Control 2015; 43(6): 572-6.
[http://dx.doi.org/10.1016/j.ajic.2015.01.021] [PMID: 25748924]
] to assess the risk of catheter-related urinary tract infection. These applications have started to be used in the same way that other care and health management applications are used.

In Japan, many applications for visiting nurses have been developed for the management of visit schedules and for the entry of user information or service plans. Visiting nurses are becoming familiar with these applications. However, few applications have been developed to assist visiting nurses in the process of helping service users.

The protocol application for visiting nurses examined in the present study was designed to assist nurses in preventing, assessing the presence of, and dealing with catheter blockage in visiting nursing settings. The mobile protocol application was designed to prevent errors in the observation route and order by providing automatic guidance. Although this mobile protocol application has not previously been tested in terms of its effects in actual visiting nursing settings, the efficacy of the protocol, when used on paper, has been demonstrated [8Maeda S, Takiuti T, Manabu T. Development of “the visiting nurse urinary monitoring protocol”-visualization of the working (in Japanese). HOUMONKANGO TO KAIGO 2017; 22(6): 484-90.]. As the protocol has been found to be effective for preventing catheter blockage, assessing the presence/absence of such a blockage, and dealing with the development of catheter blockage, an application version of the protocol was proposed as a countermeasure against errors in the observation route and order, which were a problem with the paper-based protocol. The purpose of the present study was to clarify issues related to the full-scale use of this protocol application using data from group interviews with visiting nurses.

2. METHODS

We held meetings to explain the prototype mobile application of the protocol (Table 1) for affiliated visiting nurses at four visiting nurse stations, conducted interviews with these nurses to clarify issues related to the use of the application, and analyzed the data from these group interviews.

2.1. Participants and Data Collection Period

We recruited the participants by requesting the cooperation of a representative of the visiting nurse department and of all visiting nurse station managers working for a corporation that supervises multiple visiting nurse stations. We organized a meeting to explain the prototype mobile application of the protocol. We required that visiting nurses participate in the meeting, but we did not consider whether managerial staff were present, working form, or other factors.

We collected data using focus group interviews. The focus group interviews were held at four different venues. Three focus groups had eight participants, and the fourth had two participants, for a total of 26 study participants. The focus group interview is a method used to gather data on participants’ feelings and opinions. Data were collected from May to June 2017.

2.2. Data Collection Method

We held a meeting at each visiting nurse station. After the participants experienced the operation of the mobile protocol application, we conducted group interviews with the nurses at each visiting nurse station. Each focus group interview lasted approximately one hour or until the topic was covered to the satisfaction of the participants and the interviewer. The interviews were audio-recorded and transcribed verbatim. The interviews were conducted by the first and second authors.

2.3. Details of the Focus Group Interviews

A semi-structured interview guide with open-ended questions was used. The focus group interviews covered the following topics on the mobile protocol application: (1) the application’s structure and content; (2) operability; (3) portability; (4) possibilities for use, effects, and expectations; and (5) concerns about using the application (Table 1). The contents of the focus group interviews were audio-recorded with the consent of the participants. A short questionnaire was administered to the participants at the end of each meeting. This questionnaire was used to collect data on individual attributes (years of experience working as a nurse, years of experience working as visiting nursing, presence or absence of experience with indwelling bladder catheter management, and presence or absence of experience dealing with catheter blockage). The documents explaining the mobile protocol application, which were shown to the participants, are presented in Fig. (1) and Table 2.

2.4. Data Analysis Method

We collectively analyzed the data on the 26 participants at the four visiting nurse stations instead of conducting a separate analysis for each meeting. Content analysis was used to analyze the transcript data. Content analysis was chosen because it offered a flexible method for developing and extending knowledge on the participants’ visiting nursing experiences. The second author was the primary coder of the study data. She discussed the codes with the first author throughout the coding process. If disagreement occurred, these authors referred to the original transcripts for clarification. Credibility was achieved by adopting maximum variation in the selection of participants and through prolonged engagement with the data.

(1) The attributes of the participants were tabulated.

(2) Regarding the results of the group interviews, statements were extracted from verbatim transcriptions prepared based on the recording of each group interview (Group Interviews 1 to 5). A minimum number of words were established for this extraction to ensure that the meaning of the extracted statements could be clearly understood. The content of these statements was then classified, with sentences (including a subject and a predicate) taken as the classification unit. Phrases and sentences that were not directly related to the protocol were deleted. Finally, each sentence was coded and classified into categories and subcategories containing other sentences expressing similar content.

2.5. Ethical Considerations

We obtained the approval of the institutional review board of Kanazawa Medical University for the implementation of the meetings and the data collection (I 147). This study was conducted in accordance with the Helsinki Declaration. We provided verbal and written explanations to the managers of the visiting nurse stations and to the visiting nurses regarding participation in the meeting, research participation, and the publication of the data, and we obtained written consent from all participants. The study data were not stored as identifiable information, so individuals and affiliations could not be identified. Other data were stored in a secure environment.

Fig. (1)
Actual screens of the mobile application.


Table 1
Details of the meetings to explain the prototype mobile protocol application.


Table 2
Structure of the mobile application screens.


3. RESULTS

3.1. Attributes of Participants

We held meetings involving 26 visiting nurses at four visiting nurse stations. Eight nurses participated at each of three visiting nurse stations, and two nurses participated at one visiting nurse station. The mean period of experience working as a nurse was 16.4 years (range: 1–35 years), the mean period of experience working as a visiting nurse was 7.2 years (range: 1–23 years), and 25 participants had experience with managing indwelling catheters and dealing with catheter blockage (one participant had no such experience).

3.2. Group Interview Results

After the participants experienced the operation of the mobile protocol application, we conducted group interviews. The group interviews lasted 20 minutes, 21 minutes, 13 minutes, and 15 minutes at the four visiting nurse stations. A total of 61 statements were extracted from the group interviews, which we divided into 69 phrases. After deleting 22 phrases that were not directly related to the purposes of this study, the remaining 47 phrases were classified into categories and subcategories according to the similarity of the content of the phrases. The phrases were classified into five categories: possibilities for the use of the mobile application, possibilities for further use of the application by nurses, suggestions for the use of the application by caregivers and nursing care workers, the burden associated with the use of the mobile application, and opinions and desires for improvements in the mobile application (Table 3). One subcategory was defined for the category of possibilities for the use of the application, and two subcategories were defined for the other four categories.

Table 3
Results of the group interviews about the mobile protocol application.


4. DISCUSSION

4.1. Points Requiring Improvement

4.1.1. Burden Associated with the use of the Mobile Application

Some participants commented about a burden associated with operating the application and carrying of the device during a home visit. Visiting nurses would be required to enter or write the regular records of their nursing visits in addition to entering information into the mobile protocol application, which would be extra work for them. Overall, 23.0% of visiting nursing records were found to be electronic in a 2015 survey [17The National Association for Visiting Nurse Service. ICT for visit nurse Tokyo of publication 2019; 4-5.], and this increased to 58.8% in a 2017 survey [18Adachi H, Maeda S, Murakado N. The situation and related factors of possession and use of information and communication technology in home-visit nursing care services. Japanese J Telemed and Telecare 2019; 15(1): 10-5.]. This indicates that the electronic conversion of visiting nursing records is likely to continue to grow in the future. If the mobile protocol application is incorporated into recording software, the extra work created by the application would be avoided. The burden associated with carrying the device at the time of the home visit was mainly about operating the device while also taking care of patients and about a sense of distrust toward the operation of the device. As Dorte et al. reported that users of visiting nursing have a positive impression about the use of tablet devices by nurses [19Vilstrup DL, Madsen EE, Hansen CF, Wind G. Nurses’ use of iPads in home care—What does it mean to patients? Comput Inform Nurs 2017; 35(3): 140-4.
[http://dx.doi.org/10.1097/CIN.0000000000000304] [PMID: 27787296]
], this practice does not appear to lead to a sense of distrust among patients. Future research should investigate patient awareness and attitudes regarding visiting nurses bringing the mobile application version of the protocol with them and entering records during home visits. This protocol itself is not necessary if the prevention of catheter blockage can be performed and assistance at the time of blockage can be provided independently on the basis of information on long-term indwelling catheter users. However, the application still has the advantage of accumulating information on catheter blockages and displaying patient history in list form. Users of this protocol should be limited to visiting nurses with little experience caring for indwelling catheter users for whom the cause of catheter blockage is unknown and observations of symptoms need to be accumulated. In a set of guidelines for the development of electronic material for use in nursing practice, Chee et al. argued that “researchers should define the meanings and effects of digitalization for research projects and populations [20Chee W, Lee Y, Chee E, Im EO. Practical guidelines for development of web-based interventions. Comput Inform Nurs 2014; 32(10): 504-11.
[http://dx.doi.org/10.1097/CIN.0000000000000088] [PMID: 25153046]
].” Statements made by participants in the present study regarding the burden associated with the use of the application suggested that visiting nurses did not know what the effects of the mobile application would be. It is necessary to clearly show and notify stakeholders of the effects when the system begins to be used on a large scale. Previously, several articles have reported the development of applications for use by patients [10Kho SES, Lim SG, Hoi WH, Ng PL, Tan L, Kowitlawakul Y. The development of a diabetes application for patients with poorly controlled type 2 diabetes mellitus. Comput Inform Nurs 2019; 37(2): 99-106.
[http://dx.doi.org/10.1097/CIN.0000000000000485] [PMID: 30407213]
, 21Foster M. A mobile application for patients with heart failure: Theory and evidence-based design and testing. Comput Inform Nurs 2018; 36(11): 540-9.
[http://dx.doi.org/10.1097/CIN.0000000000000465] [PMID: 30045131]
-23Wang J, Yao NA, Liu Y, et al. Development of a smartphone application to monitor pediatric patient-reported outcomes. Comput Inform Nurs 2017; 35(11): 590-8.
[http://dx.doi.org/10.1097/CIN.0000000000000357] [PMID: 28471762]
], but the number of studies of this type has been limited. As there is no fixed method for application development, previous work has variously reported application content/processes centering on theory [9Egawa M, Okamoto K, Nishimura F, et al. Development of a smartphone application system of symptom-recording to manage premenstrual syndrome and its clinical use. J Japanese Soc of Psychosom Obstetrics and Gynecol 2015; 21(1): 105-13., 10Kho SES, Lim SG, Hoi WH, Ng PL, Tan L, Kowitlawakul Y. The development of a diabetes application for patients with poorly controlled type 2 diabetes mellitus. Comput Inform Nurs 2019; 37(2): 99-106.
[http://dx.doi.org/10.1097/CIN.0000000000000485] [PMID: 30407213]
] and development driven by expert discussion and consensus [17The National Association for Visiting Nurse Service. ICT for visit nurse Tokyo of publication 2019; 4-5.]. Under these circumstances, it is valuable that this research clarified the viewpoint of the burden associated with the use of the mobile application.

4.1.2. Opinions and Desires for Improvements in the Mobile Application

Some participants made statements about the content of the mobile application and potential improvements in its functions. Comments regarding the application’s content were mainly related to the entry of urine volume. As the timing of urination was unknown, some participants requested ambiguity in the entry of this information, and other participants requested the ability to enter numerical values. The urine volume item needs to be examined to allow visiting nurses to enter the data in accordance with real-world conditions such as whether they are performing a direct visual check or basing their entry on reports from family members.

Other participants expressed opinions such as “Are reference pages necessary?” and “This protocol should include techniques and procedures for the management of catheter blockage.” Reference pages may be unnecessary for experienced nurses; however, these pages should not be deleted because multiple statements suggested that this protocol could be used for basic nursing education, and it is possible for the reference pages to be viewed only by those who want to see them. Bladder irrigation and catheter replacement were mentioned as aspects of dealing with catheter blockage that should be included. However, these procedures involve risks such as urethral injury caused by forced insertion, depending on the physical condition of the patient. If individual circumstances are not clear, the patient’s care should not be guided by the mobile application. Thus, we think that it would be dangerous to add detailed information on these techniques and procedures.

4.2. Suggestions for Use

4.2.1. Possibilities for the use of the Mobile Application and Possibilities for Further use of the Application by Nurses

In terms of possibilities for the use of the mobile application, participants commented that the photo function and the past data viewing function of the application could be used in visiting nursing. Participants’ comments regarding possibilities for further use of the application by nurses included ideas about using the application in nursing education, including both basic nursing education and continuing nursing education, and about using the application as an inter-professional collaboration tool. With increasing population aging and the ongoing promotion of home medical care, the number of users of visiting nursing is rapidly increasing in Japan [24Journal of Health and Welfare Statistics Press 2019 /2020 (in Japanese). Tokyo of publication: Health. Labour and Welfare Statistics Association 2019; 66(9): 193-4.]. The mobile protocol application examined in the present study provides care instructions and incorporates learning functions. Applications have begun to be used in basic nursing education and in continuing nursing education [11Lall P, Rees R, Law GCY, Dunleavy G, Cotič Ž, Car J. Influences on the implementation of mobile learning for medical and nursing education: qualitative systematic review by the Digital Health Education Collaboration. J Med Internet Res 2019; 21(2): e12895.
[http://dx.doi.org/10.2196/12895] [PMID: 30816847]
, 12Kim H, Suh EE. The effects of an interactive nursing skills mobile application on nursing students’ knowledge, self-efficacy, and skills performance: a randomized controlled trial. Asian Nurs Res (Korean Soc Nurs Sci) 2018; 12(1): 17-25.
[http://dx.doi.org/10.1016/j.anr.2018.01.001] [PMID: 29463484]
]. A previous study found that a smartphone application providing nursing scenarios for patients with chronic diseases may play an important role in the acquisition of knowledge and the development of self-efficacy in basic nursing education [25Kang J, Suh EE. Development and evaluation of “chronic illness care smartphone apps” on nursing students’ knowledge, self-efficacy, and learning experience. Comput Inform Nurs 2018; 36(11): 550-9.
[http://dx.doi.org/10.1097/CIN.0000000000000447] [PMID: 29901475]
]. However, because the protocol examined in the present study was not prepared for education, the learning screens would need to be enhanced for use in basic nursing education. Catheter blockages are strongly associated with urinary tract infections, and the application can also be used in continuing nursing education by incorporating the guidelines for the prevention of urinary tract infection into the learning screens. The application could also be used as an inter-professional collaboration tool through the sharing of accumulated patient data. However, in the transmission of medical information, the application would need to comply with the government’s Guidelines for Safety Management of Medical Information Systems, Version 5 [26Ministry of Health. Labour and Welfare Guidelines for security management of health information system edition five (in Japanese) 2019. Available from: http://www.mhlw.go.jp/file /05-Shingikai-12601000-Seisakutoukatsukan-Sanjikanshitsu_Shakaihoshoutantou/0000166260.pdf]. Although security protection measures are expensive, previous work has shown that visiting nurses use private smartphones and tablets for their work at visiting nurse stations [19Vilstrup DL, Madsen EE, Hansen CF, Wind G. Nurses’ use of iPads in home care—What does it mean to patients? Comput Inform Nurs 2017; 35(3): 140-4.
[http://dx.doi.org/10.1097/CIN.0000000000000304] [PMID: 27787296]
] and that nurses working at medical institutions in the Philippines use personal smartphones for business conversations and professional text message transmission [27Bautista JR. Filipino nurses’ use of smartphones in clinical settings. Comput Inform Nurs 2019; 37(2): 80-9.
[http://dx.doi.org/10.1097/CIN.0000000000000482] [PMID: 30299305]
], indicating the need for security measures regarding both information protection and information and communication technology device provision. Security measures related to information protection and information and communication technology devices require nurses to be knowledgeable about information and communications technology. This raises the question of how much computer literacy nurses are required to have. It has been reported that most nurses have moderate anxiety about the use of computers [28Top M, Yılmaz A. Computer anxiety in nursing: An investigation from Turkish nurses. J Med Syst 2015; 39(1): 163.
[http://dx.doi.org/10.1007/s10916-014-0163-5] [PMID: 25526705]
], and nurses’ computer skills are associated with their attitudes toward the introduction of information technology in nursing care [29Gürdaş Topkaya S, Kaya N. Nurses’ computer literacy and attitudes towards the use of computers in health care. Int J Nurs Pract 2015; 21(Suppl. 2): 141-9.
[http://dx.doi.org/10.1111/ijn.12350] [PMID: 24804813]
]. In this study, we found that nurses expected various functions for application development. However, to develop these functions, it is necessary to have an educational system that improves nurses’ information and communications technology skills.

4.2.2. Suggestions for the use of the Application by Caregivers and Nursing Care Workers

The participants’ suggestions for the use of the application by caregivers and nursing care workers concerned two points: possibilities for the use of the application by caregivers and nursing care workers and the potential for difficulty in the use of the application by caregivers and nursing care workers. The latter group of comments were related to the perceived inability of older adults to operate devices such as digital tablets. Home nursing care involves not only nurses but also physiotherapists, occupational therapists, and home helpers. In home care in Japan, family members provide nursing care in addition to public services, and the timeframe over which they provide this care tends to be long and to include catheter management. It has also been reported that the observation of conditions such as urine volume and the presence or absence of fever by family members is associated with the frequency of catheter blockage [3Maeda S, Takiuti T, Komatsu T, et al. Current status of long-term indwelling urinary catheter emergency management by visiting nurses. HOUMONKANGO TO KAIGO 2012; 7(9): 888-92. [in Japanese].]. Regarding the operation of the application, some study participants raised the concern that caregivers in Japan tend to be older adults, who may not be able to use the application [30Ministry of Health. Labour and Welfare, Fact-finding survey on long-term care for the elderly 2019. Available from: https://www.mhlw. go.jp/shingi/2007/11/dl/s1109-10c.pdf]. However, because of the rapid diffusion of smartphones (from 9.7% of the population in 2010 to 75.1% in 2017) [31Ministry of Internal Affairs and Communications. Usage trend of ICT service 2019. Available from: http://www.soumu.go.jp /johotsusintokei/whitepaper/ja/h30/html/nd252110.html], we believe that caregivers, regardless of their age, will be able to use the application if its operation is simple. In a 2019 survey conducted by Hyojin et al., more than 60% of respondents in their 70s, on average, made positive comments regarding the use of a portal site [32Son H, Nahm ES. Older adults’ experience using patient portals in communities. Comput Inform Nurs 2019; 37(1): 4-10.
[http://dx.doi.org/10.1097/CIN.0000000000000476] [PMID: 30188353]
]. Furthermore, it has been reported that older adults can adapt to using applications. In Japan, the roles of patients, family caregivers, and care workers are expanding [33Cabinet Office. Government of Japan: Japan ― White Paper and Annual Reports 2015. Available from: https://www8.cao.go.jp /kourei/whitepaper/w-2019/html/zenbun/s1_2_2.html]. Although the application examined in the present study cannot currently be used by caregivers and nursing care workers, it is necessary to clarify the roles of these individuals in preventing and responding to catheter blockage and to consider the possibility of developing a tool to raise awareness regarding daily observation and nursing care. Our application may contribute to the expansion of self-care, and we hope to find a way to ensure this contribution.

4.3. Limitations of the Study

A limitation of this study was that the participants were limited to four visiting nurse stations. The results may differ depending on the attributes of the visiting nurses, affiliated medical institutions, and indwelling catheter users. Furthermore, the suggestions made regarding the use of the mobile application by caregivers and nursing care workers are only speculation. In the future, we should investigate the possibilities for the use of the application by caregivers.

CONCLUSION

The group interview results revealed several issues for the use of the mobile protocol application:

1. The addition of functions of photos and data accumulation may expand the use of the application in visiting nursing care. However, accumulated data are presently only available for viewing, which is a limitation of the application.

2. It is expected that the application will be used for basic nursing education, continuing nursing education, and as a tool for cooperation with members of other professions. However, because the application was not specifically developed for education, learning screens should be added for use in nursing education. It will also be necessary to take safety management measures for the transmission of medical information if the application is to be used as a tool for cooperation with other professionals.

3. As application users are expected to increase in the future, this mobile protocol application is expected also to be used by caregivers and nursing care workers. We need to clarify the roles of these individuals in preventing and managing catheter blockage and examine the content of the application accordingly.

4. At present, visiting nurses need extra time and effort to enter information into the mobile protocol application in addition to completing the regular visiting nursing records. We need to find ways to avoid this extra work in the future, such as by incorporating the mobile protocol application into recording software.

5. The use of the mobile protocol application will be a burden for visiting nurses with sufficient knowledge and experience in the assessment and management of catheter blockage. We need to clarify the users of this protocol and the effects and aims of the mobile application.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

We obtained the approval of the Institutional Review Board of Kanazawa Medical University, Japan, for the implementation of the meetings and the data collection (I 147).

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Written informed consent was obtained from all the participants.

AVAILABILITY OF DATA AND MATERIALS

The study data were not stored as identifiable information, so individuals and affiliations could not be identified. Other data were stored in a secure environment.

FUNDING

This study was supported by a Grant-in-Aid for Scientific Research (B: No. 16H05601) for 2016–19.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We thank Jennifer Barrett, Ph.D., from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

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