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 [17], and this increased to 58.8% in a 2017 survey [18]. 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 [19], 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 [20].” 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 [10, 21-23], 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 [9, 10] and development driven by expert discussion and consensus [17]. Under these circumstances, it is valuable that this research clarified the viewpoint of the burden associated with the use of 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.

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 [24]. 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 [11, 12]. 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 [25]. 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 [26]. 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 [19] and that nurses working at medical institutions in the Philippines use personal smartphones for business conversations and professional text message transmission [27], 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 [28], and nurses’ computer skills are associated with their attitudes toward the introduction of information technology in nursing care [29]. 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.

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 [3]. 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 [30]. However, because of the rapid diffusion of smartphones (from 9.7% of the population in 2010 to 75.1% in 2017) [31], 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 [32]. 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 [33]. 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.