Identifying and prioritizing key risk factors in internet-based shared nursing services from the nurses’ perspective: a hybrid multi-criteria decision-making approach

A single-center exploratory study involving 30 shared nurses in Zhejiang Province, China, identified trust-building with patients and families, service outcomes that meet expectations, home-care training, clinical problem-solving and emergency handling, and composure during difficult situations as the highest-weighted risk factors in internet-based shared nursing services. The research used a hybrid multi-criteria decision-making approach to rank perceived risks and compare their importance with current management performance; it did not measure whether particular interventions reduced adverse events or improved patient outcomes.

The March 2026 survey was conducted at Taizhou First People’s Hospital, a tertiary general hospital in Zhejiang Province. Participants had to be registered on a shared nurse platform, qualified to provide home-based nursing services, and involved in shared nursing for at least six months. Thirty of 33 returned questionnaires were valid, yielding a valid response rate of 90.91%. Most participants were women, held bachelor’s degrees and intermediate professional titles, and had 11–20 years of nursing experience. Their mean shared nursing experience was 4.8 ± 1.94 years.

The investigators adapted the risk-factors section of a previously developed instrument for Internet Plus Nursing Services for older adults. The resulting Internet-based Risk Factor scale organized 27 items into five dimensions: patient and family risk assessment, external-environment risk assessment, platform and hospital supply risk assessment, nurses’ service-related experience, and nurses’ clinical core competence. The source scale had reported an overall Cronbach’s alpha of 0.970, dimension-specific coefficients of 0.803–0.973 and a content validity index of 0.941.

The 30 participating nurses served as an expert panel. They rated item importance on a five-point scale, assessed current management performance on a 10-point scale and made pairwise comparisons using a 1–9 linguistic scale. Consistent fuzzy preference relations converted the comparisons into local and global weights, while importance–performance analysis divided the 27 factors into four quadrants. No formal statistical power calculation was performed because the study used a multi-criteria decision-making design rather than a hypothesis-testing design. The consistency analysis reported a 99.22% confidence level and a 0.78% gap at the goal layer, with dimension-level confidence levels ranging from 98.65% to 99.72%.

Clinical core competence received the highest dimension-level weight, followed by patient and family risk assessment and nurses’ service-related experience. Platform and hospital supply risk assessment ranked fourth, and external-environment risk assessment ranked fifth. At the item level, establishing a trust relationship with patients or family members had the highest global weight at 0.071. Consistency between service outcomes and patient or family expectations ranked second at 0.064, adequacy of systematic and comprehensive home-care training third at 0.059, proficiency in clinical problem assessment and emergency handling fourth at 0.057, and remaining calm and orderly during difficult clinical problems fifth at 0.049.

Importance–performance analysis used a mean importance value of 0.037 and a mean performance score of 7.612. Eleven factors fell in the high-importance, high-performance quadrant, including consistency between outcomes and expectations, training adequacy and all five clinical-competence items. Five platform and hospital supply factors were classified as lower importance with comparatively high performance, while all eight external-environment factors were in the lower-importance, lower-performance quadrant.

Three patient and family factors were the only findings in the high-importance, low-performance quadrant: patient or family courtesy, educational background, and establishment of trust. The authors described these as management gaps while noting that some patient and family behaviors are beyond healthcare organizations’ direct short-term control. They proposed possible responses including communication training for shared nurses, structured expectation-setting before visits, age-tailored public education, platform alerts for users with documented inappropriate behavior and stronger safety-support mechanisms for nurses. These were proposed management responses rather than interventions tested for effectiveness in the study.

The rankings reflect how the participating nurses perceived and judged risk factors. Shared nurses may travel to patients’ homes independently or in pairs, outside the hospital environment where colleagues can provide immediate assistance, and the authors associated the high weighting of clinical competence with the need for professional knowledge, nursing skills, independent decision-making, emergency response and psychological resilience in varied home environments. The analysis did not directly measure adverse events, service quality or patient safety outcomes, and it did not establish that the proposed measures would reduce risk.

Important limitations include the small, single-center expert panel, which may limit the precision, stability and generalizability of the derived weights. The priorities also depended on subjective expert judgments and were therefore vulnerable to perception and self-report bias. Data were collected at one time point and may not remain stable as shared nursing services and the healthcare environment evolve. The authors described the findings as preliminary and called for multicenter validation with larger and more diverse panels, alongside comparison with adverse-event reports, complaint records, platform logs and patient and family perspectives.

Subject of Research: Exploratory prioritization of perceived risk factors in internet-based shared nursing services using nurse expert judgments

Article Title: Identifying and prioritizing key risk factors in internet-based shared nursing services from the nurses’ perspective: a hybrid multi-criteria decision-making approach

Article References: Xiao, J., Yang, H., Zhang, W., Wang, L., & Xu, D. (2026). Identifying and prioritizing key risk factors in internet-based shared nursing services from the nurses’ perspective: a hybrid multi-criteria decision-making approach. Frontiers in Public Health, 14, Article 1956352. https://doi.org/10.3389/fpubh.2026.1956352

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1956352

Keywords: shared nursing services, internet-based nursing, risk-factor prioritization, consistent fuzzy preference relations, importance–performance analysis, nurse perceptions, home-care training, patient-family trust, clinical competence, Zhejiang China, Identifying, prioritizing