The management of nurses in internet-based home care in tertiary general hospitals in China: a mixed methods study

Abstract

Background

China is currently implementing an “Internet-Based Home Care” program, wherein medical institutions utilize institution-registered nurses to provide door-to-door nursing services to discharged patients or those with limited mobility through an “online application and offline service” model. Tertiary general hospitals play a leading role in this program, and effective nurse management is crucial for its success. However, the overall development status of Internet-based home care in these hospitals remains unclear.

Purpose

This study aimed to investigate the current status and challenges of nurse management in Internet-based home care within Chinese tertiary general hospitals and to propose evidence-informed recommendations.

Methods

We employed an explanatory sequential mixed-methods design. From March to December 2022, we first conducted a national cross-sectional survey of 117 tertiary general hospitals. Findings from this quantitative phase informed the development of a focus group interview guide. Subsequently, a focus group was conducted with eight experienced home care nurses to qualitatively explore the underlying reasons and contextual factors behind the survey results.

Results

The survey revealed that the coverage rate of Internet-based home care in Chinese tertiary general hospitals was 64.1%. Among hospitals offering the service, 51.3% had fewer than 5% of their nurses participating, and 85% provided the service fewer than 50 times monthly. Although 97.33% of hospitals offered pre-job training and assessment, no uniform standards existed. Legal and medical safety risks persisted, and benefit distribution mechanisms among stakeholders were underdeveloped. The qualitative findings provided depth to these challenges, revealing that nurses’ positive attitudes were tempered by concerns about work-life balance and safety. Their concrete proposals centered on developing collaborative service models (e.g., with community providers), implementing standardized training and assessment, establishing fair incentive mechanisms, and enhancing safety protocols through technology and policy support.

Conclusion

This study provides a systematic analysis of nurse involvement in internet-based home care in Chinese tertiary hospitals. Based on the integration of quantitative and qualitative data, the study calls for strategic human resource policies, standardized training, robust safety measures, and supportive policies to guide the sustainable development of Internet-based home care in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04480-8.

Introduction

Home care represents a critical component of transitional and extended care, significantly enhancing the success of patient transitions from hospital to home while providing essential professional healthcare guidance to individuals with chronic illnesses and elderly patients [1].The integration of information technology has given rise to “Internet-based home care,” a model that transcends geographical limitations and offers new possibilities for care delivery [2]. As a modality that fosters new paradigms of care production and interdisciplinary practice, home care is experiencing substantial expansion worldwide [3].

Population aging has emerged as a profound social challenge globally, one that is particularly acute in China and has catalyzed a sharp increase in the demand for home care services [4, 5]. In response, the National Health Commission released the “Internet-Based Home Care Pilot Work Plan” in February 2019, defining the model as one where medical institutions leverage their registered nurses to provide door-to-door nursing services via an “online application and offline service” framework, with pilot programs launched in selected cities the same year [5, 6].

Currently, Internet-based home care in China remains in its nascent stages, confronting numerous management and implementation hurdles. Tertiary general hospitals, with their advanced resources and expertise, are well-positioned to lead in providing complex home care services [7]. Although nurses generally view this program positively [8–10], their actual participation rates remain low, posing a significant challenge to its expansion [11].

A critical gap exists in the literature: a comprehensive national understanding of how these key hospitals manage their nurses in this new program is lacking. To address this, our study utilized an explanatory sequential mixed-methods design. This design was chosen so that the initial quantitative survey could map the national landscape of nurse management, while the subsequent qualitative phase could then explore the experiences and perceptions of nurses themselves, thereby explaining the key issues identified in the survey. The findings aim to inform government agencies and relevant stakeholders in developing targeted policies to advance Internet-based home care in China.

Methods

Study design

This study employed an explanatory sequential mixed methods design [12], grounded in a pragmatic research paradigm which prioritizes the research problem and values the use of multiple forms of data to gain a comprehensive understanding [13]. The primary rationale for this design was to first use a quantitative survey to map the national landscape of nurse management in Internet-based home care and identify key challenges. The subsequent qualitative phase was then designed to collect detailed follow-up explanations from frontline nurses, aiming to elucidate, contextualize, and deepen the understanding of the findings from the initial survey. Data collection occurred from March 1 to December 31, 2022, with the quantitative phase preceding the qualitative phase.

Phase 1: Quantitative survey

Participants

A multistage sampling strategy was employed across all 31 provincial-level administrative divisions in mainland China, encompassing 22 provinces, 4 direct-controlled municipalities, and 5 autonomous regions. Initially, two cities were randomly selected from each province or autonomous region, and two districts from each direct-controlled municipality, yielding 62 cities or districts. Subsequently, two tertiary general hospitals were randomly selected from each city or district, resulting in an initial sample of 124 hospitals. Inclusion criteria comprised: (1) being a tertiary general hospital; (2) willingness to participate; and (3) having a designated manager responsible for Internet-based home care. Exclusion criteria were: (1) non-tertiary general hospitals; and (2) incomplete questionnaire responses. One questionnaire was completed by the responsible manager per hospital. The sample size was determined based on considerations of feasibility and representativeness; a sample of 124 hospitals was deemed sufficient to capture national trends.

Instrument

A novel questionnaire was developed for this study through a rigorous multi-stage process to ensure its validity and reliability. First, a comprehensive review of literature and policy documents was conducted to inform the initial draft. Subsequently, a two-round Delphi expert consultation was performed with a panel of 21 experts in nursing management and Internet-based home care from tertiary general hospitals across 11 provinces. To assess content validity, the panel of experts rated the relevance of each item on a 4-point scale. The Scale-Level Content Validity Index (S-CVI) was calculated to be 0.965, indicating excellent content validity [14]. After the Delphi method process, an expert group discussion was organized, involving 5 senior clinical nurses from the research team, to further refine the expression and logical structure of each item. Finally, a pilot test was conducted with 10 tertiary general hospitals (not included in the main study) to assess the questionnaire’s clarity, comprehensibility, and average completion time (approximately 30 min). The final questionnaire contained 37 items across three sections: (1) hospital characteristics (6 items); (2) management of Internet-based home care providers in implementing hospitals (28 items): 9 on nurse composition, 4 on training and assessment, 13 on security assurance, 2 on performance plans); and (3) reasons for non-implementation, needed support, and perceived necessity for non-implementing hospitals (3 items).Hospitals that had implemented the program were instructed to complete Sects. 1 and 2, while those that had not were asked to complete Sects. 1 and 3.(See Supplementary Material 1 for the complete questionnaire).

Data collection

The questionnaire was administered online via the Wenjuanxing platform. The landing page detailed the study’s purpose, inclusion criteria, and procedures, along with investigator contact information. Participants indicated informed consent by selecting “Yes” to proceed. Out of 124 distributed questionnaires, 117 were fully completed, yielding a 94.35% response rate. Seven questionnaires were excluded due to incomplete responses.

Data analysis

Descriptive statistics were computed, presenting frequencies and proportions. Data analysis was performed using SPSS version 26.0.

Phase 2: Qualitative focus group

Participants

Participants were purposively selected from tertiary general hospitals across China involved in Internet-based home care. Inclusion criteria required participants to be: (1) having provided over 20 home care cases; and (2) possessing more than 5 years of clinical experience. Eight nurses from four provinces (Hunan, Shanxi, Zhejiang, Jiangxi) were recruited, all from the pool of 75 implementing hospitals. Thematic sufficiency was achieved after a single focus group session. Given the participants’ shared professional roles and extensive experience, no new thematic insights pertinent to the survey-identified issues emerged upon further analysis. In explanatory sequential designs, qualitative data collection should focus on in-depth exploration of specific issues identified in the quantitative phase, rather than seeking comprehensive representativeness [15, 16]. Thematic sufficiency was assessed based on whether the qualitative data offered sufficient depth to clarify and situate the key challenges from the quantitative phase, without generating additional themes within the predefined domains [15, 17]. Conducting only one focus group was a deliberate methodological decision, consistent with the study’s explanatory sequential design. This approach enabled a focused and in-depth examination of the survey findings, while the professional homogeneity of the participants (all experienced home care nurses in comparable positions) can accelerate the process of thematic sufficiency, as participants with similar backgrounds are more likely to share common experiences and perspectives, which facilitates focused, in-depth exploration of specific issues [15, 18].

Data collection

A semi-structured interview guide was developed based on the salient issues identified in Phase 1. The guide encompassed six key questions: (1) personal feelings about involvement and impact on work-life balance; (2) perspectives on providing services during off-duty versus working hours; (3) experiences and suggestions regarding training and assessment; (4) satisfaction with remuneration and desired incentive structures; (5) perceptions of safety and recommendations for enhancement; and (6) encountered difficulties and required support. The focus group was conducted online via Zoom to accommodate geographical dispersion. Participants initially completed a brief demographic survey (age, gender, education, work experience). Two experienced researchers moderated the 2-hour discussion, which was audio-recorded and transcribed verbatim. Transcripts were meticulously cross-checked against audio recordings to ensure accuracy.

Data analysis

Thematic analysis of transcripts (NVivo) involved independent coding by two researchers, codebook development through consensus (with third-researcher arbitration if needed), and theme identification (see Supplementary Table 1). Trustworthiness was secured through member checking and researcher triangulation.

Integration of quantitative and qualitative data

The integration of the two data phases occurred at two key points [15]. First, during the study design and data collection stage (connecting), the survey results directly informed the development of the semi-structured interview guide for the focus group, ensuring that the qualitative phase explicitly addressed the salient issues uncovered quantitatively. Second, during the data analysis and interpretation stage (building), the qualitative themes were used to explain, illustrate, and provide context for the quantitative findings. This approach moves beyond merely reporting parallel findings to constructing a more nuanced explanation.

Ethical considerations

The study was approved by the Nursing and Behavioral Medicine Research Ethics Committee of Xiangya School of Nursing, Central South University (Ethics Review and Approval No: E2022122). This study followed the guidelines of the Declaration of Helsinki (World Medical Association, 2013).

Results

Respondents to questionnaires

Among 124 invited hospitals, 117 provided valid responses. Seven questionnaires were excluded due to incomplete responses.The survey response rate was 94.35% (117/124). Among the participants, 75 hospitals have carried out Internet-based home care and 42 hospitals have not, giving a coverage rate of 64.1% for Internet-based home services in tertiary general hospitals in China.

Participants of the focus group interview

A total of 8 clinical nurses participated in the group interview. All eight participants were female and held bachelor’s degrees. Their professional titles were supervisor nurse (n = 5) or associate chief nurse (n = 3). Ages ranged from 33 to 52 years (Mean = 40.75 ± 5.74), with work experience spanning 9 to 33 years (Mean = 30.5 ± 2.29).

The survey results of 75 hospitals that have carried out this programme

The characteristics of the 75 hospitals that have carried out Internet-based home care were presented in Table 1. The 75 implementing hospitals were distributed across 22 provincial divisions. The program’s duration ranged from 0 to 72 months (Mean = 22.57 ± 15.67 months). Service volume was notably limited, with 85% of hospitals reporting fewer than 50 service provisions per month.

Table 1.

Characteristics of the 75 hospitals implementing internet-based home Care (N = 75)

Characteristics	Number	Percentage (%)
Duration of the program(month)
<12	20	26.7
13∽24	25	33.3
25∽36	20	26.7
37∽48	7	9.3
>48	3	4.0
The average number of service times per month
<5	21	28.0
5∽20	28	37.3
20.01∽50	16	21.3
50.01∽100	5	6.7
100.01∽200	4	5.3
>200	1	1.3
Type of service
Home care service	75	100
Online consulting service	49	65.3
Electronic health education	43	57.3
Online outpatient service	36	48.0
Remote consultation service	26	34.7

Composition of service providers

Table 2 shows the composition of service providers of Internet-based home care in these 75 hospitals. In 51.3% of hospitals, less than 5% of the total nursing workforce participated in the program. Merely 4.0% of hospitals incorporated retired nurses into their service provision, including 2 hospitals with 1 retired nurse and 1 hospital with 5 retired nurses, while 68.0% expressed support for their potential involvement. Services were predominantly delivered during nurses’ off-duty time (81.3% of hospitals), although 44.0% endorsed the possibility of provision during working hours. Participating nurses were primarily supervisor nurses aged between 30 and 40 years.

Table 2.

Composition of service providers in the 75 implementing hospitals (N = 75)

Characteristics	Number	Percentage (%)
The proportion of the nurses participating in the program in the hospital
<1.0%	12	16.0
1.0%∽5.0%	28	37.4
5.1%∽10.0%	12	16.0
10.1%∽20.0%	7	9.3
20.1%∽50.0%	16	21.3
The proportion of the nurses participated in the program who have obtained the provincial specialist nurse qualification certificate
<10.0%	18	24.0
10.0%∽20.0%	16	21.3
20.1%∽50.0%	23	30.7
>50.00%	18	24.0
Whether retired nurses participate in the program
Yes	3	4.0
No	72	96.0
Whether nurses can provide home care services during normal working hours
Yes	14	18.7
No	61	81.3

This quantitative finding regarding off-duty service provision was further elucidated in the focus group interviews. Participants acknowledged the practical necessity of this model given current hospital staffing constraints, as one nurse stated: “Our hospital… requires nurses to use their personal spare time… as the hospitals were in a relative shortage of manpower” (N2). However, this model raised concerns about work-life balance. To mitigate this, some suggested collaborative models: “Using the Internet approach, we worked with community hospitals to have community nurses accompany us…” (N6).

Training and assessment of service providers

The vast majority of hospitals (97.33%) conducted pre-job training and assessment for participating nurses, although two hospitals did not. Training was administered by municipal health commissions or nursing associations in 4 hospitals, while 69 hospitals conducted their own internal training. Regular assessments were implemented in 76.0% of hospitals (annually: 54.4%; semi-annually: 38.6%; quarterly: 5.3%; bi-monthly: 1.7%). A conspicuous lack of uniform standards was evident across these processes.

The qualitative data confirmed the variability in training and underscored the desire for standardization. Nurses proposed establishing a national unified training and assessment system. As one participant explained, “The head nurse conducted the first round of screening… Then, the training base conducted a qualification review…In addition, the nurses must undergo a first-time on-site apprenticeship and a second-time door-to-door internship under the guidance of an experienced teacher. Only after successfully completing both internships could they continue to take orders.” (N3), indicating a multi-tiered approach that could be formalized. Another noted the advantage of being a provincial training base: “…we were authorized by the Hunan Provincial Health Commission as a training base… Therefore, the training of personnel would be more convenient” (N6), pointing to a potential model for scaling up quality training.

Security assurance for service providers

Most hospitals (75.33%) provided some form of insurance for service providers, though coverage was frequently incomplete. Alarmingly, 8.0% of the associated platforms lacked essential safety features such as location tracking, one-touch alarms, or integration with public security systems. Significant legal and medical safety risks persisted (Table 3).

Table 3.

Security assurance measures in the 75 implementing hospitals (N = 75)

Security assurance	Number	Percentage(%)
Insurance for service providers
Purchased by the hospital	9	12.0
Purchased by third-party institutions	48	64.0
No insurance	17	22.7
Purchased by the nurses themselves	1	1.3
Types of Insurance
Personal accident insurance	52	69.3
Medical liability insurance	38	50.7
Medical accident insurance	37	49.3
Types of transportation used by nurses for home care
Taking a taxi by themselves	55	73.3
Self-driving	53	70.7
Take public transportation	42	56.0
Book a car through the home care platform	10	13.3
The hospital sends a special car	2	8.0
Method of service process recording
Upload key information by taking photos	64	85.3
Electronic nursing record	46	61.3
Video recording (whole-process recording)	27	36.0
Video recording (partial recording)	19	25.3
Audio recording	4	5.3
Whether complete nursing service records during home care service
Yes	63	84.0
No	12	16.0
Whether have an evaluation feedback mechanism for service objects
Yes	67	89.3
No	8	10.7
Whether establish Internet-based home care records for service objects
Yes	39	52.0
No	36	48.0

These risks were a central concern in the interviews, where nurses proposed concrete solutions. Their suggestions included safety equipment and protocols: “We had an APP-based location tracking system and an enforcement recorder… one-touch alarm button” (N1), “We could carry legally effective consent forms for various complications…“(N2), structured patient auditing: “assess whether the patient and his family were cooperating well and whether there had been any disputes or other underlying issues during the hospitalization…Another assessment would be conducted during the home visit. If it appeared that the patient was not suitable for continued care services or a revisit, a reminder and a recommendation for the next visit would be submitted on the platform.” (N6), and strict professional boundaries: “we never crossed boundaries… this was not a matter of taking it easy” (N8). These qualitative findings provide actionable context for the quantitative data on safety assurance gaps.

Performance plans for service providers

Only 32% of hospitals had integrated Internet-based home care into their formal performance evaluation standards. Remuneration distribution exhibited considerable variation, indicating immature mechanisms for benefit-sharing among involved parties (Table 4).

Table 4.

Distribution of remuneration in the 75 implementing hospitals (N = 75)

Security assurance	Number	Percentage(%)
The proportion earned by nurses
≤ 50%	19	25.3
51%∽79%	20	26.7
80%∽100%	36	48.0
The proportion earned by hospitals
≤ 10%	61	81.3
11%∽30%	9	12.0
>30%	5	6.7
The proportion earned by platforms
≤ 10%	39	52.0
11%∽20%	23	30.7
21%∽30%	13	17.3

The interviews revealed that while income supplement was a motivator “This provides a welcome supplement to our income” (N4), nurses desired more structured and professional recognition. Proposals included “establish individual awards based on service quality and total workload” (N7) and “provide more career prospects and development space” (N3). This indicates that the current immaturity of incentive mechanisms, as quantitively found, fails to fully address nurses’ expectations for both financial and professional growth.

Non-implementing hospitals

Among the 42 non-implementing hospitals, an overwhelming majority (92.9%) acknowledged the necessity of the program. Their cited reasons for non-implementation and expressed needs for support are detailed in Table 5.

Table 5.

Status of the 42 non-implementing hospitals (N = 42)

Characteristics	Number	Percentage (%)
Whether it is necessary to carry out Internet-based home care
very necessary	27	64.3
relatively necessary	12	28.6
general	2	4.7
Not really necessary	1	2.4
unnecessary	0	0
The reasons for not running this program
Lack of relevant platform	30	71.4
Lack of unified rules and regulations	28	66.7
Lack of charging standards	28	66.7
Lack of legal protection	23	54.8
Personal safety risk	21	50.0
Most projects cannot be covered by medical insurance	20	47.6
Shortage of human resources	19	45.2
With medical risks	19	45.2
The superior did not put forward relevant requirements	9	21.4
Refer to other units in the later stage	7	16.7
Most of the service objects are the elderly, so nursing is stressful	4	9.5
The hospital has little demand for this service at present	1	2.4
Other reasons	6	14.3
The support needed if the program were to be run
Relevant platform	18	42.9
Support of medical insurance and charging	13	31.0
Support from a superior leadership	9	21.4
Establish a common standard	8	19.0
Legal protection	7	16.7
Support of relevant policy	7	16.7
Manpower support	7	16.7
Relevant training and experience guidance	7	16.7
Security assurance	5	11.9

Focus group interview themes

Analysis of the qualitative data revealed three central themes: (1) nurses’ attitudes toward the program, (2) concrete proposals for its development, and (3) their expectations and perceived support needs. And the complete thematic structure with supporting quotes is available in Supplementary Material 2 are integrated with the quantitative findings in the narrative above, the findings corresponding to these themes were systematically used to explain, contextualize, and provide actionable insights into the key quantitative findings.​.

Theme 1: Attitudes of nurses

Participants expressed predominantly supportive attitudes, highlighting three main aspects: Recognition and Willingness, Enhanced Professional Value, and Income Supplement.

Theme 2: Proposals for improvement

Participants provided detailed proposals for standardizing and securing the service. Their recommendations specifically addressed the need for formalized service models (e.g., hospital-community collaboration), rigorous and standardized training/assessment protocols, enhanced safety assurances (e.g., technology, clear protocols), and more structured incentive mechanisms that value both financial compensation and professional development.

Theme 3: Expectations and supports

Participants voiced strong expectations for five forms of support: (1)Insurance Coverage: Universal desire for the inclusion of home care services within medical insurance schemes.(2)Defined Scope of Practice: Clear national guidelines delineating positive and negative lists of authorized services to mitigate risk. (3)Prescribing Authority: Hoping for appropriate medication prescribing rights within their competency at the policy level. (4)Family Support: Acknowledging the importance of understanding and support from their own families to enable participation. (5)Public Awareness: Advocating for stronger publicity efforts aimed at patients and families to increase awareness and acceptance of the service model.

Discussion

Principal findings

This pioneering national study delineates a nascent stage of Internet-based home care in China’s tertiary hospitals, characterized by formidable challenges in nurse deployment, safety protocols, training standardization, and incentive structures. The explanatory sequential mixed-methods design proved instrumental in unraveling a central paradox: nurses’ broad endorsement of the service model is starkly counterbalanced by their reticence to participate. Qualitative insights illuminate this discrepancy, revealing that pragmatic apprehensions regarding excessive workload, personal safety, and inadequate incentives frequently supersede positive attitudes. These operational constraints appear rooted in overarching structural deficiencies within the program’s framework. Furthermore, the competing institutional priorities—such as academic research, clinical teaching, and acute patient care—inherent to tertiary hospitals likely foster a measured, even cautious, approach to integrating this novel initiative [19].

The overwhelming consensus among non-implementing hospitals on the necessity of Internet-based home care underscores its perceived strategic value. Their cited barriers mirror known challenges: the foundational need for a functional IT platform, the guiding role of clear industry regulations, and the critical importance of a viable reimbursement model supported by medical insurance [20]. A predominant apprehension remained the potential disruption to core inpatient nursing services [1], highlighting the delicate balance administrators must strike between innovating care delivery and maintaining the integrity of existing hospital operations.

Human resources and service models

The conspicuously low participation rate, wherein a majority of hospitals engage less than 5% of their nursing staff, signals a profound strain on existing human resources. The heavy reliance on off-duty hours (81.3%) for service delivery intensifies concerns regarding work-life integration, a particular pressure for a workforce predominantly comprising women who often shoulder significant domestic duties [21]. Our qualitative findings corroborate this tension; nurses expressed reluctance to undertake additional roles that further erode the boundary between professional and personal time, echoing concerns documented elsewhere [22]. Although introducing flexible shifts and engaging retired nurses (who must retire at age 55 but often remain capable and energetic)could alleviate workforce shortages [15], our interviews suggest that integrating home care into regular working hours is currently seen as impractical due to staffing constraints. This staffing impasse underscores the attractiveness of alternative service paradigms voiced by participants, notably formalized hospital-community collaboration. Embedding community nurses within home visits could potentiate several advantages: leveraging localized patient knowledge to enhance efficiency, bolstering safety through co-visitation, and facilitating seamless care transitions from hospital to home [23, 24]. Such a model resonates with the core tenets of integrated Primary Health Care [25, 26] and presents a viable strategy to circumvent the current impracticality of scheduling home visits within regular working hours. Consequently, near-term strategies must prioritize refining off-duty service logistics (e.g., via flexible scheduling algorithms) while concurrently championing the development of structured collaborative frameworks with community providers to forge a more resilient and sustainable ecosystem [27, 28].

Training and assessment mechanism for nurses

The near-universal yet heterogeneous provision of pre-service training constitutes a critical vulnerability, potentially compromising service quality and patient safety. The salient deficit is the absence of a unified, standardized curriculum and competency assessment. Frontline nurses themselves identified this lacuna as a primary concern, advocating for the establishment of a multi-tiered, systematic approach comparable to established international paradigms, such as that of Japan [29]. A strategic path forward involves instituting a nationally standardized training and credentialing system. This could entail designating qualified tertiary hospitals as provincial training hubs [30] and implementing a graded certification schema aligned with nurse seniority and procedural complexity, building upon pioneering local efforts [31].

Performance plans and incentive mechanisms for nurses

The underdevelopment of incentive structures, coupled with the marginal integration of home care into formal performance appraisal systems, has demonstrably eroded nurse motivation. Existing literature suggests that remuneration is frequently perceived as incommensurate with the invested time and effort [32]. A fundamental impediment is the dual challenge of non-standardized pricing and limited medical insurance reimbursement for services [33]; this creates a scenario where costs are prohibitive for patients yet unsustainable for providers. Our qualitative data enrich this understanding, revealing that nurses’ expectations extend beyond financial compensation to encompass professional acknowledgment and career development opportunities. This implies that incentive mechanisms require a holistic redesign—rewarding both quantitative output and qualitative excellence, and formally recognizing home care participation as a valuable component of professional growth and advancement, alongside essential reforms in pricing and insurance coverage [30, 33].

Safety assurance for nurses

Concerns for safety—spanning legal, clinical, and personal domains—persist as a dominant deterrent. Quantitative findings highlighting gaps in insurance protection and safety infrastructure corroborate previous reports of nurses’ perceived vulnerability [34]. Moreover, inconsistent documentation practices, such as incomplete service records, amplify potential liabilities. The qualitative narratives, however, yielded actionable mitigation strategies. Participants emphasized the necessity of a multi-faceted safety system integrating technological aids (e.g., GPS tracking, emergency alerts), rigorous pre-visit patient assessments, unwavering adherence to professional boundaries, and reliable access to multidisciplinary support teams [35, 36]. Equipping nurses with dedicated logistical resources and establishing robust protocols for real-time teleconsultation are paramount for effective risk management during home visits [37, 38].

Strengths and limitations

A key strength of this study is its mixed methods approach, combining a first-of-its-kind national survey with in-depth qualitative insights from experienced clinical nurses, providing a comprehensive understanding of the issue, which may provide ideas for further research on the formulation of Internet-based home care services in tertiary general hospitals in China. However, limitations must be acknowledged. First, given that only one focus group was conducted, the qualitative phase may not fully capture the diversity of nursing experiences. While thematic sufficiency was reached in relation to the survey-informed issues, additional groups or interviews could have further validated emergent insights and explored a wider range of contextual variations. Second, the single online focus group format may not have fully explored potential regional or operational differences in nurses’ experiences.​The online survey method may introduce self-selection bias, and the length of the self-designed questionnaire (approx. 30 min) might have affected response quality. The questionnaire, not being a scaled instrument, precluded factor analysis. The sample size, while providing national coverage, was determined based on feasibility and representativeness rather than a formal power calculation, which may limit the generalizability of inferential statistics. These limitations are offset to some extent by the use of mixed methods, where qualitative data help to validate and interpret the quantitative trends. Future research should focus on developing and validating concise measurement tools, expanding the scope of stakeholders included (e.g., patients, families, platform developers), and conducting longitudinal studies to assess long-term outcomes.

Conclusion

This study provides a comprehensive overview of nurse participation in Internet-based home care within Chinese tertiary general hospitals by integrating quantitative survey data with qualitative insights. It systematically identifies major challenges across key domains, including human resources, safety assurance, training, assessment, and incentive mechanisms.Based on the synthesis of findings, particularly the concrete proposals and perceived needs expressed by the nurse participants, the following recommendations are proposed to guide the program’s development:

1. Develop strategic human resources policies to encourage nurse participation. Nurses suggested exploring models for integrating retired nurses and optimizing scheduling through personalized dispatch systems to mitigate work-life balance issues.

2. Establish a national unified training and assessment system. Participants emphasized the need for standardized protocols and tiered certification to ensure quality and competence.

3. Create transparent and equitable performance and incentive mechanisms. Nurses expressed a desire for remuneration that adequately rewards participation and is linked to career development, moving beyond simple income supplementation to include professional recognition.

4. Enhance safety protocols and legal safeguards.Recommendations derived from nurses’ proposals include implementing mandatory insurance, deploying safety technology (e.g., location trackers, alarms), clarifying legal documentation, and establishing multidisciplinary support structures.

5. Advocate for policy support, the qualitative data highlighted nurses’ expectations for policy support to integrate home care services into medical insurance systems, clearly define the scope of practice, and explore the possibility of granting appropriate prescribing authority within a regulated framework.

6. Increase public awareness and foster understanding among patients, families, and nurses’ own families to build support for the program.

7. Develop integrated service models, Participants strongly advocated for​ formalizing hospital-community partnerships for collaborative home visits, enhance resource utilization, and establish a more efficient and sustainable healthcare delivery system.​

Although in its early stages, Internet-based home care in China is progressing. The findings of this study, grounded in the direct data and voiced needs of clinical nurses, can inform policymakers and health authorities in refining strategies. Learning from international best practices tailored to the local context is advised to guide the standardized and sustainable development of this vital service.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Ziwei Cao and Liqing Yue conceived and designed the study. Ziwei Cao, Huan Peng, Bin Peng, and Bingyu Li investigated and collected the data. Ziwei Cao and Bin Peng analyzed the data and wrote the draft. All authors (Ziwei Cao, Liqing Yue, Bin Peng, Bingyu Li and Huan Peng) revised and checked the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This study was funded by the Nursing Research Sub-project of the China Health Talent Training Programme, Health Human Resources Development Center, National Health Commission, P.R.China. (2021-HLYJ-003).

Data availability

All data generated or analyzed during this study are included in this article.

Declarations

Ethics approval and consent to participate

The study was approved by the Nursing and Behavioral Medicine Research Ethics Committee of Xiangya School of Nursing, Central South University (Ethics Review and Approval No: E2022122). This study followed the guidelines of the Declaration of Helsinki (World Medical Association, 2013). Informed consent to participate was obtained from all of the participants in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.