The use of technology in Welsh health care is increasing, partly because of the COVID-19 pandemic (Hutchings, 2020) and as a result of national policy such as A Healthier Wales (Welsh Government, 2018) and the Primary Care Model for Wales (Welsh Government, 2019). Although digital consulting is relevant to all health professionals, one study found nurses were the greatest users of it (Kim et al, 2018). Nevertheless, it can be unclear how technology or the use of digital tools in nursing can support nurses and their patients, particularly where care relies on physical or hands-on skills.
The term digital nursing (DN) is employed broadly to refer to anything and everything digital used in nursing but there is no standard definition. DN can involve a variety of technologies that may be aimed specifically at individual patients, and includes telehealth, telecare and mobile applications, such as Healthy.io (National Institute for Health and Care Excellence, 2020). It can also include electronic tools that support nurses in their role, such as electronic patient records, electronic staff rostering systems and e-scheduling systems.
Previous work has been carried out on DN; for example, the Royal College of Nursing (2023) has published a variety of guidance focusing on the future of digital nursing, digital roles and digital innovations. However, there appears to be a gap in understanding of the perspectives of nurses working in primary and community nursing services. Therefore, the aim of this study was to explore what digital health care means to these nurses based on their firsthand professional experiences. This research forms part of a larger digital nursing partnership study conducted by Technology Enabled Care (TEC) Cymru (2023), an all-Wales service funded by the Welsh Government and hosted by Aneurin Bevan University Health Board, established to provide oversight and direction for technology-enabled care in Wales.
Methods
A mixed-methods approach was taken. To design and conduct the research, TEC Cymru collaborated with a consultant nurse in child health and the national nurse lead for primary and community care affiliated with the Strategic Programme for Primary Care in Wales. The multidisciplinary research team included expertise from industry, digital delivery and academia as well as clinical health and social care.
Based on early observations and insights, the researchers designed an online survey (employing the SurveyMonkey platform) that used a range of question types. For example, scales of 0-100 were used to allow participants to rate their confidence in using certain tools. This wide range was chosen as it would allow participants more variability in comparison with simple Likert scales. Open-ended questions, including asking participants to define DN, allowed nurses more freedom to share their thoughts.
The survey link was distributed using snowball sampling via email by the two nurses working on the project and via a range of nursing networks and events, with the aim of reaching an audience of nurses across Wales, primarily working in community and primary care.
Informed consent was given by participants via a statement of consent with a compulsory tick box they had to complete before survey submission. Within the survey, nurses could opt to take part in a semistructured interview to discuss their views further. The interview questions were based on preliminary survey data. Interviews were conducted by four independent researchers and took place over the phone or via a videoconferencing platform.
Data were collected over a period of 5 months between June and October 2022. Quantitative survey questions were descriptively analysed, and free text and interview data were thematically analysed.
Ethical approval
Full ethical approvals and risk assessments were received from Aneurin Bevan University Health Board Research and Development Department (reference number: SA/1114/20), followed by national approval obtained from all other health boards in Wales.
Results
A total of 249 responses were collected by the survey, and 25 of the participants took part in semistructured interviews. These were nurses working mainly in the community and primary care across all health boards in Wales. Their professional areas can be seen in Table 1.
Table 1. Participants' areas of work
| Nursing area | Number of participants (n=249) |
|---|---|
| District nursing | 80 (32.1%) |
| Community nursing (adult/paediatric) | 49 (19.7%) |
| General practice | 46 (18.5%) |
| Health visiting | 11 (4.4%) |
| Community mental health (adult/children) | 8 (3.2%) |
| School nursing | 6 (2.4%) |
| Community learning disability (adult/paediatric) | 4 (1.6%) |
| Care home/nursing home | 4 (1.6%) |
| Work across more than one area | 12 (4.8%) |
| Other | 29 (11.6%) |
From both the open survey answers and interviews, it was apparent that nurse participants had diverse perspectives on what digital nursing meant. Some viewed it positively as a way to aid patient care by facilitating the sharing of digital information and improving quality of care. Others saw it primarily as a classification of areas of nursing that were purely digital. Several had not heard of the term ‘digital nursing’.
Four main themes were identified from the survey and interview data: access; impact on care; technology; and digital future. These were further divided into subthemes and are discussed in turn below.
Themes
Access
Three key areas were identified in relation to access (Table 2). DN was seen as providing quicker, easier and improved access to services for both patients and professionals, which many nurses felt would not previously have been possible. The importance of ease of use was commonly mentioned throughout the responses; nurses wanted easy access to all DN tools in one place to avoid delays in information sharing and ensure user-friendliness.
Table 2. Theme: access
| Subthemes | Examples |
|---|---|
| Increasing access to health care (patient) | ‘Any technology that makes care provision more user friendly/accessible.’ Advanced nurse practitioner, general practice‘Great for the wider community, additional accessible resources for patients, especially those in employment.’ General practice nurse‘… Digital interactions with service users, using technology to be more accessible to clients.’ Health visitor‘Technology is a lot more convenient now for everyone, we can see patients quicker now through eConsult than face to face.’ Advanced nurse practitioner‘So, you can be sitting the house with them, talking, showing them that help is here … They can get out and get working on what they need to do faster.’ Lead advanced nurse practitioner |
| Efficient and effective | ‘Using technology in order to effectively and efficiently complete our work.’ Community children's nurse, community nursing‘The ability to undertake work more effectively.’ Mental health nurse, community mental health (adult/children)‘Good to have info in one place and be able to access clinical workstation.’ District nurse‘iPads and apps are so much quicker. In my day-to-day work including all these … my day would be 10 times harder without. It would be a long day.’ Advanced nurse practitioner |
| Access to information (professionals) | ‘Our iPads allow us access to our emails and Teams wherever we are. We can access the Welsh clinical portal, so we have access to all manner of results and letters and information about our patients, which is great … if we're going out to see someone in their own home, we can get the information while we're there, assuming that … we've got wi-fi.’ Lead advanced nurse practitioner‘Using and sharing information via digital service which is timely.’ District nurse‘This is where all patients’ notes and consultations are recorded on computer instead of completing paper notes, and these can be shared more easily for all disciplines involved in a particular patient's care.’ Community nurse (adult), district nursing |
Some nurses talked about creating their own digital tools, such as advanced spreadsheets, within their teams. Nurses in community settings found iPads convenient for accessing patient records and information in patients' homes. Nurses believed that using digital tools to share patient information enhanced access to health care, improved patient care and promoted better multidisciplinary collaboration within the profession.
Impact on care
In the survey, nurses were asked whether they felt DN had a positive impact on patient outcomes, with a score of 0 indicating no impact and a score of 100 indicating a positive impact. Nurses rated this on average 72, with the most common score being 100, which strongly suggests that nurses felt that outcomes for patients were improved by DN.
Nurses identified DN as something that could improve care by ‘improving patient outcomes’, through building ‘rapport’ and ‘enhancing and enabling care’, including care already being provided (Table 3). Improving patient outcomes formed part of many definitions within the survey responses, with a focus on how technology and DN can aid in how care is delivered to achieve this. The use of DN methods such as remote and virtual consultations allowed rapport to be built and sustained with patients, enabling an improved level of care in many cases.
Table 3. Theme: impact on care
| Subthemes | Examples |
|---|---|
| Patient outcomes | ‘Where nurses use a digital format to provide patients with information and advice on improving their health and wellbeing.’ Healthcare assistant/support worker, community nursing (adult/paediatric)‘A process to improve patient care, increase accessibility and empower patients.’ Health visitor/lecturer, education‘The other thing that I've done recently is asked if we can put steroid cards on [Accurx] since we have patients on high-dose steroid inhalers for asthma or [chronic obstructive pulmonary disease] so, if they go hospital, they've only got to show the hospital [this on their phone].’ Specialist practice nurse‘I think it's empowered patients so they can do more googling themselves. A lot of the younger patients are quite happy to google and get more information online. But your elderly group, they would rather have a printout. You can just access the information a little bit better.’ General practice nurse‘When everybody has access to the same system, the theory is there shouldn't be any delays in treatments, therapies, referrals.’ Community mental health nurse |
| Enhancing and enabling care | ‘We've got an asthma hub that the patients use, so they take over their own conditions, so they can do reviews using the app and see their medications. A lot of the time, it is people who are working, so they use email whilst they're in work which is much easier than a phone call or face to face. The apps are brilliant.’ Advanced nurse practitioner‘Access to technology that enables both client- and staff-facing interactions.’ Community children's nurse‘Use of digital platforms/devices aimed at delivering enhanced and sustainable nursing care.’ Specialist nurse, community nursing |
| Enhancing communication | ‘Integrated support that enhances care, not causes more issues.’ Senior staff nurse, district nursing‘Nursing remotely (non face to face) utilising technology for communication between nurse and patient.’ General practice nurse‘Well, all our records are currently paper … sharing would be easier because we've got some colleagues working over in a different office, so notes are going between those offices … I guess records would be much more secure.’ Health visitor‘Can input data straight away rather than it being lost in communication, as especially at times when you want to write up notes after a home visit or if a safeguarding issue comes up during a school clinic, we have to wait until we go back to base and put all that information in.’ School nurse‘In this day and age with safeguarding, I think [digital nursing's] the way forward. It comes back to communication every time and, if we've got it at our fingertips and everybody can access it, I think it's much safer than just paper records. You have to make sure they're stored properly, whereas if it's digital it's a bit easier with password and encryptions, it's better all round.’ Health visitor |
Nurses highlighted how DN tools could ensure that the care process was as streamlined and quick for individuals as possible. The use of digital tools could allow people to actively take part in their care, feel involved in decision-making, and promote independence by allowing them to self-manage their health and wellbeing.
Technology
A large emphasis was placed on technology when defining DN, with nurses referring to ‘linking of digital platforms’, ‘digital records’ and ‘being online’ (Table 4). Digital notes in particular were one aspect of DN that was highlighted both during the survey responses and throughout the follow-up interviews.
Table 4. Theme: digital and technology
| Subthemes | Examples |
|---|---|
| Linked together | ‘Use of IT computers, telephones, text messages, emails.’ General practice nurse‘Emails, telephone and video appointments, online referrals and referral updates.’ Advanced nurse practitioner, general practice‘Linking in with digital platforms to communicate and share care throughout appropriate nursing contacts.’ Specialist nurse, care home |
| Being online | ‘Online nursing programs that support care.’ General practice nurse‘Anything involving online – computer technology to deliver or assist with care.’ Practice nurse‘Digital working is incorporating information technology and resources used ie iPad, laptop and digital tools for everyday working (desktop, Outlook, Calendar, Teams, emails, health roster, Malinko, electronic staff record, training). All used to improve work effectiveness, time management, patient safety, effectiveness.’ Team leader, district nursing |
Some nurses felt there was still a high reliance on paper notes and documents within the profession, which could sometimes cause issues. Several identified how digital notes could aid decision-making, improve safeguarding, enable continuity of care and support efficient working practices (Table 4).
‘[Also] we do paper referrals that go internally and then they get logged on WCCIS [Welsh Community Care Information System]. So, there's still a high reliance on paper. Obviously, the goal is to be paperless, but it feels like we're such a long way off it.’
Lead advanced nurse practitioner
‘Would help to aid decision-making. At the moment, things are handwritten so there are no digital notes, so there's no bank where we can store this information at the moment for school nursing. Retrospective notes can sometimes lose that essence of what you're trying to capture when you're there.’
School nurse
This was less evident in responses from nurses working in GP settings, where digital notes were the norm (Table 5).
Table 5. Types of technology and systems used
| Subthemes | Examples |
|---|---|
| Video conferencing | ‘eConsult is brilliant as well; we have used a lot of it. That is becoming more popular – we are encouraging patients to use that a lot more now.’ Advanced nurse practitioner‘I had a patient come in who I was not able to diagnose. She had a rash and said what you think of this, and I said, well, I don't know, but I took a photo, and I uploaded it into our eConsult system for the GP to have a look. There was no GP available to have a look while she was there you know, so these tools, I think they so beneficial and you know, it would save an appointment and they would get back to her.’ Nurse manager‘I use the Accurx all the time. It's great, so if you do a contraception review you can send advice, something that you forget in the consultation, you can add the information.’ General practice nurse‘Digital can also facilitate remote access via links like Attend Anywhere so people can choose consultation via this system.’ Advanced nurse practitioner |
| Digital notes | ‘All our admission and discharge summary letters are digital.’ Paediatric practice nurse‘Electronic record-keeping with the aim to reduce and stop paper notes. The records can be accessed remotely in patient homes and ensure records are timely and accurate.’ Advanced nurse practitioner‘We're a paperless practice. Everything is recorded and it can be logged into from various portals … We can log in remotely from home which happened with a lot of practitioners through the pandemic. You know, where there's no face to face with patients, it makes such a difference.’ Nurse manager |
| Telephone | ‘School nurses run a clinic and this was done through telephone during the pandemic as we didn't have the equipment available to use the digital technology in that way.’ School nurse‘I use WhatsApp with all the families through my work phone, and they found that very useful to communicate.’ Paediatric specialist nurse‘They do like having the asthma reviews over the phone if they're stable – you know, people are busy, they've got working lives so, if they're pretty stable, you can do it over the phone.’ General practice nurse |
There was a vast variety of different types of technology and systems used by nurses across the different specialties. Technologies such as eConsult or Accurx (Table 5) were seen positively as they allowed patients to be seen without attending the GP surgery in person, which saved them time and the need to travel. It was noted that not all community nurses have access to this system as it is primarily used within general practice; this may be an area of technology that could be explored more within other community settings in the future.
Some nurses also identified the use of the telephone within their role as being related to DN, as many had been running telephone clinics since the pandemic. Others had been using it as a triage service or to communicate with patients' families.
Regardless of the systems used, it was clear how important it was to nurses that these platforms and systems could be linked.
Digital future
When asked about the impact of DN on ways of working on a scale of 0 (no impact) to 100 (positive impact), the average score was 71. When defining DN, many nurses referred to it as the ‘future’. The majority of nurses also felt that DN had a place within current nursing culture, with an average score of 74 using the same scoring system:
‘The way forward in nursing, everything being accessible in one place to aid in nursing care.’
Adult community nurse
‘A new era in nursing. A good management tool. Innovative.’
General practice nurse
‘Using technology to modernise nursing and make the services more efficient.’
Adult community nurse
‘Modernised nursing using technology to assist in triaging patients and appropriately signposting or reviewing.’
Advanced nurse practitioner, general practice
There was evidence of how digital services were already modernising and transforming the way nurses worked, such as reducing the amount of travel, allowing better utilisation of nurses' time, and helping nursing move forward by advancing their skills and increasing patient care:
‘I'd say positively. You know, it all it helps us get our job done … and you know informs what we're doing and how we're how we're doing it.’
Community clinical lead nurse
‘It's easier. You don't have to travel to all these various places and then there's the parking – you can do it all online. I prefer it – it's a lot easier.’
General practice nurse
However, other nurses spoke about their preference for face-to-face consultation and communication:
‘I much prefer face to face – you can see the patient and pick up on things. Nurses use all their senses, like you can smell ketones if you've got a diabetic.’
General practice nurse
‘We still have face-to-face meetings as well. What I heard a lot from other people is that not meeting face to face is not as good for making those kinds of tactile and interpersonal bonds. It's not as good for camaraderie. So, I think it's just making sure that everyone gets that balance.’
Advanced nurse practitioner
With the constant changing of systems, one nurse commented how they felt they were now reaching a ‘happy medium’ in converting daily tasks into digital ones. However, they felt more was needed from health boards to support the use of similar systems so they could share information more easily:
‘I think we're getting to a nice happy medium now. I think we didn't have much in the way of technology then we moved onto virtual everything, and I think we're coming back to sort of a balance between the two, but yeah, I wish health boards would buy into it. The same systems to be able to share information.’
Service manager
This highlights that, despite the role of digital in both current and future practice, it should not be replacing all aspects of nursing.
Discussion
This study set out to try to understand primary and community nurses' perceptions of DN. The survey and interviews provided a wealth of information. There was evidence that, although nurses could identify digital tools used within nursing, there was no one agreed definition of what DN was. The varying interpretations of DN are likely to be because of differences in backgrounds and exposure to DN or the existing information available. This suggests a need for increased awareness. Interestingly, terms such as ‘telecare’ and ‘telemedicine’ were not mentioned by the respondents, further suggesting limited understanding.
The majority of nurses identified DN had a positive impact on outcomes for patients by enhancing care, providing quicker access and enabling people to actively take part in their care, allowing them to self-manage their health and wellbeing. Nurses also described the benefits for the profession with regards to improved access to patient information and increased efficiency. As a result of these benefits, many nurses considered DN to be the future of nursing. These findings are mirrored by those of Seibert et al (2020), in which nurses in Germany discussed DN having a role in improving clinical outcomes, saving time and aiding decision-making and communication. Similarly, Curtis and Brooks (2020) interviewed nurses working in nursing homes in England who identified how DN could improve communication and quality of care and saw it as the future of health care. This suggests that nurses working in different countries and in a variety of specialties have similar views regarding the benefits of DN.
Although digital tools in health care can enhance access for some patients, it is vital to acknowledge that not all patients may wish to use or have access to such technology. As DN evolves, a balance must be struck to prevent discrimination against individuals who lack access, knowledge, ability or willingness to use these digital services.
It is evident from the data that defining DN is not simple; some key phrases used when defining digital nursing have been selected and can be seen in Figure 1. Based on these broader terms, the authors propose the following more concise working definition: digital nursing refers to the development and use of any technology within the nursing profession to improve ways of working and patient care.
Nurses also spoke consistently about digital notes in relation to what DN was, more so than any other type of technology. In some areas, such as general practice, the use of digital notes was embedded; however, in other areas, such as district nursing, specialist nursing and some children's and health visiting services, it was less common. This focus suggests that nurses recognise the value of digital notes in supporting safe, timely and effective care, the sharing of information with colleagues and members of the multiprofessional team and supporting efficient working practices. Therefore, enabling access to digital notes, which support nurses' practice and safe care for patients, appears to be a priority.
Digital transformation is continuing to take place and has been described by Brown and Hartley (2021) as playing an integral part in community nursing. DN undoubtedly has many benefits, for nurses, patients and the wider multiprofessional team. However, in the move towards the increasing use of digital tools, particularly those that enable access to nurses or support self-management, it is important that nurses continue to provide a range of options for those who are unable to use such technology. Consequently, incorporating an individual's knowledge and ability to use technology into holistic nursing assessments appears to be of growing importance as the use of digital tools increases.
Limitations
One limitation of this study population is the wide variations in response rates between the different community nursing groups, the reasons for which were not clear. Furthermore, although the results show broad positivity towards digital nursing applications among respondents, it is essential to consider non-respondents' perspectives. To address this, the researchers made multiple contact attempts with non-respondents. The response rate may have be affected by the vague definition and poor understanding of digital nursing, potentially confusing nurses. With increased awareness through this study and TEC Cymru's upcoming work in Wales on remote monitoring and virtual wards, future research may achieve better participation.
Recommendations
Based on the results of the survey and interviews, a series of recommendations have been identified that, if implemented, would help embed the use of digital tools within primary and community nursing in Wales:
- Agree and share with nurses an all-Wales definition of digital nursing, so nurses have clarity about what this term means
- Consider developing an agreed way for locally implemented digital tools that demonstrate positive outcomes for patients to be shared and implemented across Wales
- Consider how the implementation of digital notes is taken forward in a consistent way across Wales for services that currently use paper-based systems
- Encourage and promote the need to include individual patients' knowledge and ability to use technology into nurses' holistic assessments.
Conclusion
Digital nursing is not a new concept, but this study provides an understanding of what digital nursing means to community and primary care nurses in Wales and proposes a working definition based on this that can hopefully be applied more broadly. Many understand the value of digital tools within nursing and are clear about their benefits to patients, nurses and the wider multiprofessional team.
Nurses form a very large and significant part of the health and care workforce. Considering the current healthcare crisis, further research is needed in this area to explore how technology can address some of these challenges.
KEY POINTS
- There are a diverse range of perspectives on what digital nursing means
- Digital nursing is seen to provide quicker, easier and improved access to healthcare services for patients and professionals, and enhance multidisciplinary collaboration
- Nurses felt that digital nursing positively impacted patient outcomes, improved care and promoted patient engagement and self-management
- Nursing staff saw digital nursing as the future of nursing, modernising healthcare and improving efficiency
- There is a need for a clear definition of digital nursing and more awareness and support for nurses in this area
- While digital transformation is playing a crucial role in community and primary care nursing, it is essential to consider individual patients' preferences and abilities in using technology
CPD reflective questions
- How do the themes identified in this study align with your own understanding of digital nursing?
- How might a standard, agreed definition of digital nursing benefit health professionals, patients and healthcare organisations?
- How can nurses ensure equitable access to digital nursing tools while respecting patients' individual preferences and needs?