Article information

J Health Info Stat. 2024;49(3):248-261

Publication date (electronic) : 2024 August 31

doi : https://doi.org/10.21032/jhis.2024.49.3.248

Yewon Lee¹, Eunju Kwak², Mijin Park³, Jiyeon Park⁴, Jungjae Kim⁵, Jisan Lee^,6

¹Nurse, Kangbuk Samsung Hospital, Seoul, Korea

²Professor, Department of Nursing, The Research Institute for Basic Sciences, Hoseo University, Asan, Korea

³Teacher, Asan Gongsu Elementary School, Asan, Korea

⁴Nurse, Soonchunhyang University Cheonan Hospital, Cheonan, Korea

⁵Nurse, Gyeonggi Provincial Geriatric Siheung Hospital, Siheung, Korea

⁶Professor, Department of Nursing, Gangneung-Wonju National University, Wonju, Korea

이예원¹, 곽은주², 박미진³, 박지연⁴, 김정재⁵, 이지산^,6

¹강북삼성병원 간호본부 간호사

²호서대학교 간호학과 교수

³아산공수초등학교 보건실 교사

⁴순천향대학교 부속 천안병원 간호부 간호사

⁵경기도립 노인전문시흥병원 간호부 간호사

⁶강릉원주대학교 간호학과 교수

Corresponding author: Jisan Lee. 150 Namwon-ro, Heungeop-myeon, Wonju 26403, Korea Tel: +82-33-760-8646, E-mail: saan2mari@gmail.com

*The Basic Science Research Program supported this study through the National Research Foundation of Korea (NRF), funded by the Ministry of Education (grant number NRF-2021R1C1C1004505).

No potential conflict of interest relevant to this article was reported.

Received 2024 April 22; Revised 2024 July 17; Accepted 2024 August 31.

Abstract

Trans Abstract

INTRODUCTION

The World Health Organization (WHO) has stated that the 21st century is the “ era of epidemic” [1]. Indeed, various infectious disease outbreaks have emerged, such as severe acute respiratory syndrome (SARS) in 2002, novel swine-origin influenza A (H1N1) in 2009, and Middle East respiratory syndrome (MERS) in 2015. In 2019, the coronavirus disease (COVID-19) emerged in Wuhan City, Hubei Province, China, exhibiting differences in pathogenesis and lethality [2].

As the COVID-19 pandemic unfolds, the escalating number of patients exacerbates the shortage of healthcare workers, negative pressure isolation rooms, medical equipment, and supplies [2,3]. Furthermore, healthcare workers have been overloaded with updating information on COVID-19 and making important decisions for the increasing number of critically ill patients [4]. Additionally, they feared being exposed to the virus despite wearing sufficient personal protective equipment [5]. Some healthcare providers were perceived as carriers of infection, resulting in demands for them to refrain from going out, and their families faced societal stigma where others were reluctant to have them attend school or work. This often led to them self-isolating to avoid transmitting the virus to their family [4]. In particular, these workers experience heavy mental burdens when isolated patients project their aggravated psychological state, such as sadness and fear, onto them [5,6]. In the workplace, common stressors frequently cited among healthcare workers include work pressure, moral distress, and work schedule [7]. These factors are typically experienced as stressors by nurses even under normal circumstances, but their impact likely intensified during the pandemic. All these circumstances and conditions can lead to burnout, low quality of sleep, depression, anxiety, and stress in healthcare workers, which could compromise the quality of patient care and threaten patient safety [8,9]. Therefore, it is necessary to deal with healthcare workers’ mental health, as it affects their attention, understanding, and decision-making [10].

In 2024, 54,546 mobile health (mHealth) apps were available in the Google Play Store [11]. Although there are numerous mental health care apps, there are no criteria to determine whether the apps are suitable and beneficial for the end user, including patients and healthcare workers [12]. Due to the pandemic, mHealth apps are more important than in-person offline health programs, as apps are more scalable and easily available [13]. The use of mental healthcare apps has improved the emotional state of healthcare workers [14]. Moreover, user-centered design enables the creation of user-tailored services by thoroughly understanding the user's environment, characteristics, and preferences, making it easier to identify what users need [15,16]. However, it is likely that universal and general mental health apps have not fully grasped the specific challenges faced by healthcare workers during a pandemic. This study aims to investigate existing apps and design the structure and user interface (UI) of the mental healing app (mHealing app) specifically tailored to the needs of healthcare workers during a pandemic. Additionally, the app is designed with the potential to be adapted for online environments in the future.

METHODS

This study was guided by the Method for extracting User Needs (MUN) in the Method of App Selection based on User's Needs (MASUN) [17,18]. Researchers who want to design the mHealth app can easily use this method to design app structures and UIs reflecting app users’ needs without requiring assistance from professional app developers. To design an application, it is imperative to first identify the target user and situation. Based on this user and situation, ideas are generated. These ideas serve as the foundation for developing personas and scenarios, with careful consideration given to the needs and priorities of the personas. Subsequently, a draft of the app is created and reviewed, culminating in the finalization of the version. In this study, the designed app's usability was virtually evaluated using a tool called Health-ITUES (Figure 1). It has been used to design apps for women experiencing menstrual discomfort [19], obese children and their caregivers [20], and people with disabilities [21]. In this study, six nurses, including one specializing in nursing informatics with experiences ranging from 4 to 27 years in senior and tertiary care settings, participated in designing the mHealing app. Their diverse backgrounds enriched the app's design process.

Figure 1.

Steps of designing ‘mHealing app’ using MUN. MUN, method for extracting user needs.

Step 1: Targeting user & situation

We discussed who will use the app and our situation to create an app that people need. Six nurses shared their clinical experiences and discussed current health issues. Demographics were provided to understand the background of the six nurses (Table 1). In addition, we searched for and reviewed mobile apps to select a target situation and app users. Thereafter, we looked for apps currently developed for us. We selected only apps that are searchable on both Android and iOS platforms.

Table 1.

Demographics for the six nurse participants

RESULTS

Step 1: Targeting user & situation

Across two discussions, six nurses shared opinions on the most necessary health issue to solve based on their experience working in their clinical background. Finally, “ mentally exhausted healthcare workers caring for COVID-19 patients,” who can use mobile apps, were selected as the target users and situation.

Six nurses sought to understand the current landscape of mental health apps for healthcare workers and analyze their content for development insights. We conducted searches using keywords “ mental health” in Korean and English according to our designated target users. 32 apps were found in the Google Play store when searching for “ mental health” using a Korean keyword, while 30 apps were found when searching for “ mental health” using an English keyword (Figure 2). After screening apps available on App Store, ten apps were included in the characteristics of the app summary (Table 2). Among these apps, ‘ Smiling Mind’ has menus for healthcare workers as meditation content. However, finding an app that provided mental healthcare targeted at healthcare workers wasn’ t easy.

Figure 2.

Overview of app selection and screening process.

Table 2.

Summary of high-ranked mobile mental health apps

Step 2: Brainstorming and mind mapping

Six nurses used brainstorming and mind mapping to identify the health issues of target users and generate ideas for overcoming them (Figure 3). Six nurses were divided into two groups to discuss the target user and situation. Several topics emerged, among which we selected mental health as a problem we could address.

Figure 3.

Brainstorming and mind mapping (two groups).

Step 5: Draft version of app structure and UI design

The app structure was designed as a flowchart by combining the user needs list (Figure 4). Thereafter, a draft version of the mHealing app was designed. The app operates on a membership basis if users choose. Depending on the user's perceived mental distress, assessments are conducted, and if the scores exceed a certain threshold, counseling is recommended as a priority (counseling is available regardless of assessment scores). Users can access information about or indirectly experience topics such as food, travel, exhibitions, and concerts online. They can also engage in activities like games, meditation, and music. There are features for chatting with others facing similar concerns or keeping a diary. Finally, there is a feature for evaluating the program or app.

Figure 4.

Flowchart of ‘mHealing app’.

Step 7: Final version of mHealing app user flow

The user flow of the mHealing app is presented in Figure 5.

Figure 5.

User flow of ‘mHealing app’.

Step 8: Application usability pilot test by the Korean Health-ITUES

The usability pilot test results, based on feedback from six nurses, showed the app's impact score at an average of 4.5 out of 5, perceived usefulness at 4.4, perceived ease of use at 4.7, and user control at 3.7 (mean scores and standard deviations were rounded off to the nearest hundredths) (Table 3).

Table 3.

Results of the Korean Health-ITUES of ‘mHealing app’

DISCUSSION

In the first step of the app design process (targeting user and situation), healthcare workers caring for isolated, stressful patients were selected as target users. Nurses must continually develop their professional expertise, uphold patients’ rights, maintain teamwork through effective communication with colleagues, enhance job performance, and demonstrate nursing competencies such as problem-solving abilities [32]. However, nurses experienced significant stress and burnout during the pandemic due to their roles in managing the outbreak [33]. When nurses are under job stress and experience burnout, these competencies are not adequately utilized, leading to negative impacts on patient safety [34], and a decline in the quality of care [35]. Healthcare workers have been further drained by the moral stress and disenchantment caused by the challenges of providing care with inadequate clinical resources [7]. The pandemic has left them exhausted, increasing the need to care for their mental health [4].

While mental health apps have been developed for various professional groups, the unique challenges faced by healthcare workers, especially nurses, during crises like the COVID-19 pandemic necessitate a tailored approach. Unlike other professions, healthcare workers are in constant contact with suffering and critically ill patients, which heightens emotional and psychological strain. Moreover, the moral distress from making life-and-death decisions under resource constraints is particularly pronounced in healthcare settings.

Therefore, the mHealing app is designed to support healthcare workers’ mental health in any crisis, serving as a versatile tool in various high-stress healthcare settings. This app differs from those used in other professions by addressing specific stressors such as prolonged exposure to trauma, moral distress, and the high stakes of patient care, which are less prevalent in other job environments. By focusing on these unique aspects, mHealing app aims to provide more effective and relevant mental health support for healthcare workers, particularly nurses, ensuring they can maintain their essential competencies even under extreme stress.

A review of existing mental healthcare apps indicates a wide range of users, with menus limited to meditation, music, or stretching. However, it is essential to reflect on users’ needs to significantly impact using the mHealth app [36]. The customizable mHealing app is based on the needs and mental health conditions of healthcare workers caring for isolated, stressful patients. The app allows users to connect to psychiatrists according to their needs and conditions and choose programs such as diaries, chats, meditation, games, music, concert/exhibition information and viewing, food recipe videos, eating shows, and traveling indoors.

Nurses and scholars with experience caring for COVID-19 patients in the infection control team and dedicated COVID-19 hospitals participated in the design stage of the mHealing app. With end users participating in overall app development from the beginning to the evaluation stage, the user-centered design has been proven to be effective in terms of accessibility, usability, credibility, and effectiveness in the development of mHealth apps [15,16]. In other words, the mHealing app is expected to be accessible, usable, credible, and effective for its target users.

During the persona development stage, we crafted two personas representing key user groups: the head of the infection control team and a nurse in the COVID-19 ward, ensuring the app addresses diverse needs within healthcare settings. Ward nurses who take care of COVID-19 patients are exhausted as they need to be aware of the latest updated information and, under stress regarding possible infection, have to resolve the increased demands of patients in isolated environments and treat an increasing number of critically ill patients [5,6]. During a new infectious disease epidemic, members of the infection control team suffer from increased mental exhaustion due to overwork, responsibility, and limitations of capacity [37]. Therefore, these two personas are accurate representatives of mHealing app users. The personas are suitable for developing mental healthcare apps to relieve the mental exhaustion of healthcare workers during a pandemic.

The mHealing app was assessed using the Health-ITUES. The assessment confirmed that the mobile health app is effective, useful, and easy to use [26]. The tool has proven reliable and valid in evaluating the usefulness of mHealth technology in community-based adults with chronic diseases [27]. In this study, as a result of the pilot test, the app was confirmed by receiving high scores in all areas of effectiveness, usability, and control. Impact, perceived usefulness, and perceived ease of use averaged more than 4 points. The user control part was less than 4 points, but it is because it is assumed to be used. In this assessment, impact and perceived usefulness received relatively high scores, representing expectations and effects for the program and thus reflecting the authors’ needs and priorities. In addition, perceived ease of use shows the user's ability to utilize the app. Thus, the selected target was an appropriate representation of the end user. In contrast, it seems necessary to supplement the items of user control. This is related to the user's interaction with the app after using it. As the app was assessed virtually in this study, user control could be re-evaluated and supplement the app after its implementation.

The study has a few limitations. In the targeting user & situation stage, we were unable to search for existing apps using a variety of keywords. Future studies would benefit from referencing apps found using a broader range of keywords. In addition, when discussing the range of mental health, the app structure and UI were categorized based on participants’ experiences and personas due to the lack of clear standards and scope for mental healthcare apps. In future studies, we expect to develop an app that will follow the advice of mental health professionals. Furthermore, this study proposed a mental health app for healthcare workers during the pandemic, but the occupational group of personas was not diverse and was limited to nurses. If various healthcare workers, such as doctors and radiologists, participate in the design stage of an app, it could provide more tailored mental healthcare.

Using the app to understand the mental state of healthcare workers is a useful way to care for their mental health in situations where social distancing is necessary due to the pandemic. In addition to the pandemic, healthcare workers are always exposed to the risk of mental exhaustion. Future studies should consider actual application development and verification of its effect on those exposed to exhaustive situations, such as healthcare workers caring for patients as usual and during a pandemic.

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