Home care, Nursing informatics, Self-care, Virtual reality



  1. Goldsmith, Denise M. MPH, MS, RN, FAAN
  2. Flash, Sara BS
  3. Holdnack, Jim PhD
  4. Brennan, Patricia Flatley RN, PhD


Immersive virtual reality computer programs provide new experimental and treatment interventions that hold great promise for nursing. Immersive virtual reality uses sensory cues to represent real-world environments in a way that makes participants feel as if they are in a physical space different from the one in which they currently exist. As the acceptance of immersive virtual reality as a clinical and experimental tool has grown, so has the need to ensure that the context depicted in the environment mirrors both the sensory and the task requirements of the real-world situation. Here, we describe the use of nurse expert key informant group interviews to generate requirements that must be fulfilled in immersive virtual reality environments designed to evoke and engage participants in self-management tasks. An expert panel of four home care nurses participated in three sessions designed to elicit details of common home care challenges, frequency of variation, and typical participants. More than 20 potential scenarios were identified. The design team later used this information to create design requirements for two key scenarios and subsequently develop immersive virtual reality environments for use in research studies, mapping sensory and functional expectations to immersive virtual reality implementations. Challenges in mapping from key informant group findings to requirements are addressed.


Article Content

In recent years, immersive virtual reality (IVR) has emerged as an efficient research instrument to study a variety of healthcare concerns and to create innovative interventions.1,2 Designing realistic and relevant IVR environments is a challenging task that benefits from the knowledge and experience of expert key informants. This article describes how the staff of the Advanced Visualization Branch (AVB) of the National Institute of Nursing Research of the National Institutes of Health engaged expert home care nurses in the design of an IVR environment intended to support future studies of self-care management in the home and community. Immersive virtual reality is a computer technology using specialized devices designed to present visual and sensory cues that mimic real-world environments. Studies support IVR as a therapeutic intervention for a wide variety of health conditions and have demonstrated positive patient outcomes.3-5 Clinical uses have focused primarily on education, exposure therapy, and sensory feedback for conditions such as chronic pain, anxiety, phobias, and eating disorders.3-5 In health professional education, there is a growing use of IVR to teach complex procedures6 as well as to study complex phenomena and treat patients.7 The variety of uses for IVR makes it an important instrument to explore in the growing field of healthcare research and practice.


Recently, IVR has become more widely used in healthcare research and patient care because of the availability of consumer-grade, moderately priced technologies that can convey health-relevant sensory cues and physical space layouts. Immersive virtual reality enables the engagement of participants in simulated real-life activities, while affording researchers greater ability to control for external factors and testing conditions.1 An IVR environment allows researchers to study real-world phenomenon without needing to accommodate for unstable, changing conditions found naturally in real-life. Immersive virtual reality allows for a controlled experimental condition to be tested systematically multiple times with the same participant or across participant groups.8 Using IVR, researchers can assess changes in performance over time under the same experimental conditions.9 One goal of utilizing IVR in patient care is to improve participants' ability to complete a complex task as if they are in real life, by creating a virtual environment where the participants feel immersed and present.8 Immersive virtual reality has the potential to be highly beneficial in nursing research, as it may provide a way to safely and systematically study instrumental activities of daily living and self-care management in a realistic and adaptable environment. Importantly, creating IVR environments that effectively mimic real-world encounters and self-management challenges requires understanding of the everyday environments of the home and community. The process of translating these challenges to guide the design of immersive environments is called design requirements gathering and is the focus of this article.


Self-care Management and Health Outcomes

Successful self-care management is an important contributor to positive health outcomes. After leaving clinician-directed care in a hospital or rehabilitation facility and upon returning home, many patients with chronic illness struggle to find effective ways to manage their health within their everyday lives.10,11 There are many factors that make it challenging for patients to understand clinician-prescribed treatment regimens and then to integrate these new or ongoing treatment plans into their daily routine.12,13 Importantly, not understanding how to modify clinician-provided guidance into what is realistic in patients' homes can lead to gaps in self-care management.14 Patients with chronic illness are often required to learn extensive and complicated information about their diagnosis and how it could change their ability to complete instrumental activities of daily living. Chronic illness treatment plans require a patient to learn how to manage medications, recognize and address symptoms, and create a routine that allows for illness management while also continuing their daily schedule alongside their treatment plan.12,13,15 The combination of these factors can lead a patient to become overwhelmed and interfere with implementing their treatment plan. Realistic and familiar environments, experienced through IVR, may help advance nurse researchers' understanding of the challenges of self-care management in the home. This may also help researchers indicate points of interventions that could be delivered in vivo or through IVR.


A key challenge lies in the gap between patients' cognitive capacity for understanding clinician instructions and clinicians' expectations for the individual. Patients in one study on chronic illness reported being able to recall and state treatment expectations; however, they also reported a lack of understanding on how to perform some of the required self-care activities. As a result, they were less likely to adhere to recommendations and successfully perform self-care management activities.12 This difference in understanding between a patient and clinician can result in unrealistic expectations for how patients are able to manage their chronic illness. Patients with chronic illness also report a misunderstanding in how their treatment plan can be affected by various factors in their life, including fitness levels and job responsibilities.14 A patient's misunderstanding about how to incorporate a treatment plan into his/her daily-living activities can lead to frustration and impaired self-care management. It is possible that leveraging IVR for research would support the identification of clinical interventions that could mitigate failures during transition from clinician-directed care to self-care management and might also provide patients with a place to rehearse the self-care management behavior in a context familiar to where that behavior will be needed.


Home Care Nurse Experts as Key Informants

Self-care management in the home is a complex, unstructured activity influenced by many facets, including the clinical problem as understood by the patient, the tasks that must be addressed, and the physical environment within which these intersect. Obtaining expert nurse perspectives can provide a basis for generating design requirements for IVR and ultimately guide study design. Home care nurses, because of their intimate knowledge of the home living experiences of patients and common self-care management needs, are crucial to understanding patients' behaviors, challenges with self-care management, and adherence to treatment plans. Therefore, they serve as credible experts to inform IVR design requirements for research of patients with self-care management challenges. Home care nurses are responsible for ensuring that treatment plans can be implemented successfully into a patient's life.16 Expert home care nurses recognize that each person's home life is unique and have developed the perspective that enables them to holistically evaluate each patient's unique environment to ensure successful self-care management. Understanding the barriers and facilitators of successful self-care management is crucial for helping patients become more able to self-manage their chronic illness. This understanding, gleaned from expert home care nurses as frontline stakeholders, provides useful guidance in designing IVR environments that support the future study and implementation of self-care management interventions.17


Group approaches, such as key informant interviews, are information-gathering methods that provide first-hand accounts of the field of interest.18,19 Past studies on chronic illnesses have used these approaches to further understand the perspectives of patients and clinicians in establishing self-care treatment plans.12,14 In this article, we report on a series of key informant group interview sessions comprised of experienced home care nurses who describe specific self-care management challenges patients face in managing their chronic illnesses in the home and community environment. The expertise of home care nurses helps IVR designers comprehend the challenges of self-care management in the context of chronic illness and obtain a unique perspective on the factors that are most supportive or detrimental to a patient's successful self-care management. Additionally, this expertise aids in the exploration of innovative technology, such as IVR, to assist in self-care management tasks in the future.



The first step of this engineering design project was to gather design requirements that would inform the development of IVR environments intended to mitigate self-care challenges for individuals with chronic illness. We invited highly experienced home care nurses to participate in a series of key informant group interviews. Inclusion in this effort required that each participant was an advanced practice nurse at the master's degree level and had greater than 5 years of hands-on experience as a home care nurse serving a community of patients with complex chronic illness. Home care nurse leaders in the local community were contacted for referral to nurses who met the inclusion criteria. Six nurses who met the criteria were invited and four agreed to participate. The average length of home care experience for this cohort was 25 years. Nurse participants were offered a small honorarium as compensation for their time. Initially, two 90-minute sessions, via remote Cisco Webex Meetings, were held 4 weeks apart. A third follow-up session, via remote Cisco Webex Meetings, was held 7 months after completion of the second session. All three key informant interviews were led by an experienced nurse (D.M.G.) from the AVB development team. Data from these interviews were collected through detailed notes and audio recordings of the interview sessions. A detailed summary document was created from the session recordings, reviewed for accuracy by the key informants, and supplied to the AVB development team.


Key Informant Group Interviews

In the initial interview session, participants were introduced to the primary objectives of the AVB of the National Institute of Nursing Research. These objectives included the exploration of using IVR technology to improve self-care management tasks for patients with chronic illness and to explore sensory cueing for psychomotor performance in a digital environment of realistic clinical scenarios. To advance these objectives, our key informants were first presented with the logistics of the group interview process and their responsibilities as a member of the group. The key informants were not required to have knowledge of, or experience with, innovative technologies such as IVR. However, it was important for them to understand the connection between their expertise in home care nursing and the future research objectives of the AVB. Therefore, a brief overview of IVR technology was provided, and its future potential as a therapeutic intervention to improve patient health was reviewed. The key informants were shown a video, via a computer monitor in a first-person perspective, of a patient traversing a simulated IVR home environment (see Supplemental Digital Content 1, This prototype depicted the home-based locations of a diabetic person's self-care activity and demonstrated how a participant in an IVR environment could manipulate the items needed for self-care, such as those needed for self-administered insulin. The video demonstrated how a participant within an IVR environment could navigate by walking or using a technical teleport feature to jump quickly between certain key locations within the virtual home. The participant in the video used a point-and-click apparatus, which appeared as virtual hands, to pick up certain items such as medications and move/drop/throw them almost anywhere around the IVR home space.


Following the presentation of IVR as a newly emerging technology in healthcare, semistructured interviews using probes and open-ended questions were utilized to facilitate identification of common self-care management challenges faced by patients with chronic illness in the home environment (Table 1). Key informants were asked to describe common self-care management challenges that they had observed in their practice.

Table 1 - Click to enlarge in new windowTable 1 Key Informant Interview Questions

During the second key informant interview session, participants were asked to review the summary document from session 1 for accuracy, clarity, and further consideration. Additional probes and open-ended questions aimed to gather greater detail were posed to the group (Table 1). During this session, key informants were encouraged to identify and reach consensus on the most common and clinically consequential self-care management challenges observed in their home care practice. They were asked to prioritize and recommend which scenarios might have the greatest potential for improvement with the application of an innovative and potentially effective IVR intervention. The third and final key informant interview session was held 7 months after the second session. During this session, key informants were asked to validate and clarify in greater detail specific clinical scenarios (Table 1).


Analysis of Key Informant Interview Content

Audio recording content from the first two interview sessions were reviewed and consolidated into summary documents by the lead author. We used a topical analysis approach according to established engineering principles.20 Two members of the development team (D.M.G., S.F.) reviewed the summaries, documenting key themes and repeated topics from each session. The results of this effort were then shared with the AVB technical design team for review and consideration. It was imperative to select scenarios that would have the potential for a positive clinical outcome for multiple patient populations and be amenable for development in IVR. As a result, the design team used clinical priorities and technical considerations as criteria to select the self-care management scenarios most amenable for development. The clinical criteria outlined below informed our design requirements and reflects the importance of the problems we aim to address.


* Common: The frequency of the challenge among patients with a specific chronic illness


* Significant: Likelihood that a behavior change associated with the scenario would improve the clinical outcomes for a patient and reduce healthcare system utilization


* Widespread: The extent to which the problem is found across multiple different patient populations



We used these clinical priorities to select a scenario that was common among patients with chronic illness, had a significant impact on the patients' health outcomes, and was not isolated to one patient type or disease state. Technical consideration for development of these clinical scenarios in IVR included whether sensory-rich IVR environments could support realistic execution of the psychomotor skills required to complete the task and could effectively reproduce relevant environmental conditions. We also considered whether well-known limitations of virtual reality (lack of haptics/tactile feedback, motion sickness, and the inability to explore fine motor movement) would be a detriment. The content from the key informant interviews provided guidance to develop IVR design specifications and requirements for sensory cueing in environments in which self-care management challenges arise, both within the home and larger community.


Workflow Analysis and Design Requirements

Utilizing information gathered from key informant interviews, the development team completed detailed workflow analyses for selected scenarios. Workflow analyses were developed from the first-person (patient) perspective and did not include potential caregivers. As part of this process, we outlined in detail the relevant stimulus, the order of the required steps to complete the selected tasks, and their interdependencies. Cognitive and behavioral requirements necessary to complete the tasks in a virtual environment were also included. From these detailed workflow analyses, we extracted design requirements to produce functional specifications for the planned IVR environments. These documents will frame the engineering development. The timeline of key informant interviews and the analysis procedures are outlined in Supplemental Digital Content 2 (see Supplemental Digital Content 2,



Key Informant Group Interviews

During interview session 1, our key informants identified and validated clinical scenarios in which more than 20 self-care management challenges could be found in the daily lives of individuals with chronic illness (Table 2).

Table 2 - Click to enlarge in new windowTable 2 Self-care Management Challenges Identified by Expert Home Care Nurses

During interview session 2 and using the criteria listed in the methods section, the key informants reached consensus on seven of the scenarios that they thought had the most significant clinical consequence for their patients with chronic illness. A summary of details provided by key informants regarding each of these seven scenarios and a description of how they might be represented in IVR are found in Table 3.

Table 3 - Click to enlarge in new windowTable 3 Selected Self-care Management Challenges and Potential IVR Research Scenarios

Although all seven of the scenarios met the clinical criteria, the AVB research and development team identified two scenarios that also met the technical considerations. The team determined that these two scenarios were most likely to be effectively represented and evaluated in an IVR environment. We chose to explore grocery store food selection among patients with heart failure managing dietary restrictions and home-base complex medication management.


Food Selection According to a Dietary Restriction

From the key informant interviews, we learned that many patients with heart failure who suffer poor outcomes related to dietary sodium intake are often unaware that the foods selected during grocery shopping may not conform to their sodium restriction. Food selection while shopping with a dietary restriction requires a person to comprehend the relationship between the information on the nutritional label and their specific dietary restriction. Key informants encouraged us to explore the potential for an immersive virtual grocery shopping experience to improve food selection behaviors for these patients.


To begin the process, we created a workflow analysis of a grocery store shopping experience for a person with a dietary sodium restriction (Table 4). Cognitive and behavioral requirements for completing this task are included. This analysis was completed as if the patient, not the caregiver, were engaged in the shopping task. To maximize an IVR experience, we chose to focus on in-store shopping where an immersive virtual grocery store would facilitate observation of food selection and meal planning behaviors. In our workflow analysis, the "Stimulus" is the anticipated trigger that initiates a specific "Task." Content found in the "Visual Cues" column describes specific environmental assets needed to complete the task. These cues are in addition to standard grocery store stimuli that help to create a realistic IVR environment. "Cognitive Requirements" are the mental processes needed to understand the required task and how to perform it. "Behavioral Requirements" are actions required by the participant to complete the task.

Table 4 - Click to enlarge in new windowTable 4 Workflow Analysis of Grocery Shopping With Dietary Sodium Restrictions

Using the results of the grocery shopping workflow analysis, we created a design requirements document (Table 5). This document includes users' interactions within the IVR environment as well as the virtual objects, spatial layout, and environmental features required to study the self-care management scenarios of interest. Using the design requirements document, we were able to translate the workflow analysis results effectively into specific functional specifications for our engineering team to implement.

Table 5 - Click to enlarge in new windowTable 5 Design Requirements for IVR Grocery Store

Complex Medication Administration in the Home

The key informants also related that ineffective home-based medication management skills are associated with increased healthcare utilization, including emergency department visits.21 Our key informants described the use of a medication dispensing device called a "pill box" to assist patients and improve the consistency and accuracy of adhering to a complex medication regimen. A pill box in this context is a common device used to contain and organize medications needed for in-home medication management.22 It requires the person to read instructions and sort, organize, count, and place a pill in the appropriate slot in anticipation of subsequent medication consumption. It requires organizing specific doses according to the day of the week, time of day, and aligning the organization with the physical characteristics of the pill box. We completed a workflow analysis outlining the use of a pill box within an IVR environment (Table 6).

Table 6 - Click to enlarge in new windowTable 6 Workflow Analysis for Complex Medication Management Using a Pill Box Organizer

According to our key informants, people often complete pill sorting activities in the kitchen. We considered what design elements would be required to study pill sorting in a virtual kitchen environment (Table 7). Some considerations included the need to manipulate small items within a virtual space, the need for environmental distractions common in a real-life house, and the need for realistic materials (like a pill box) so that a participant could easily recognize and relate to the object within the virtual space.

Table 7 - Click to enlarge in new windowTable 7 Design Requirements for an IVR Pill Box Organizer Task


As part of the National Institute of Nursing Research, the AVB aims to advance nursing research in transitional home care with the use of IVR. To utilize IVR as a nursing research stimulus, it is important first to systematically develop an IVR environment that will facilitate the study of self-care management in the natural, everyday contexts of individuals with ongoing health concerns. Our long-term goals are to create IVR environments that can engage participants in these multisensory, image-intensive experiences and then evaluate the impact of these environments on health behavior. Researchers have reported that IVR technology holds great promise for both therapeutic and investigatory use in healthcare.1,2 As reported by our key informants, innumerable home healthcare scenarios exist that could be the focus of IVR research when considering the challenges complex chronic medical conditions have on daily life. To identify common and complex self-care management scenarios that are difficult for patients to complete, and that may be amenable to development in IVR environments, we engaged expert home healthcare nurses to provide information based on their knowledge and real-world experience. We applied a structured group interview process by which to extract a core set of home care situations that were important and challenging for patients and home care nurses. The perspectives of our key informant experts are consistent with those found in the literature regarding the challenges of people living with complex illness.11,12,14,16,21-23 Using the information provided by our experts, the AVB chose two areas for initial exploration in IVR: food selection based on dietary restrictions while grocery shopping and medication management using a pillbox organizer. Once we identified clinical scenarios for development and future study, we created workflow analyses to define the design requirements and functional specifications as a development framework for the engineering team.


It is well established in the literature that attention to workflow in computer system development for healthcare is crucial because "it allows for clear definition of the problem space to be addressed,"24 and various approaches to workflow analysis have been described.24 Our workflow analysis framework was created to gather as much detail as possible to guide the design framework for our engineering team. In our analyses, we include users' potential cognitive demands and behavioral expressions in addition to more typical items such as the stimulus, the order of the tasks, and their interdependencies. The detail of our workflow analyses contributed to the creation of accurate and comprehensive design requirements. These requirements can be implemented in many ways, and through an iterative design and test model, we can create usable and realistic interfaces. We think other researchers can apply this model to identify other home healthcare scenarios and to provide a standardized way to communicate with technical staff.


As evidenced by the results of our workflow analyses, self-care management tasks for patients with chronic illness are complex and are complicated by the interplay among cognitive, behavioral, and environmental factors. Individual differences in cognitive skills such as attention, memory, reading, computational abilities, learning, organizing, and executing may interact with environmental influences (product labeling, store layout, cost, etc) to produce variability in the successful implementation of newly acquired healthcare behaviors. The multifactorial nature of these challenges makes it difficult to evaluate improvement interventions. Immersive virtual reality environments are highly controllable, eliminate confounding variables, and allow for the quantifiable measurement of human behavior which can be calculated and stored for future analysis. Immersive virtual reality is convenient and economical for repeated-use cases, such as practice, therapy, or in place of venues that are not accessible to patients or caregivers.1 These characteristics suggest that using IVR for research purposes will have significant advantages over similar studies in real-life environments. The use of IVR technology provides us with the potential to observe, evaluate, and understand specific factors of self-care management challenges and provides nurses with an additional research strategy for understanding patients' responses to these challenges.


Our IVR grocery store environment will facilitate observation of a person's food choice behavior and will allow us to obtain a quantitative measurement of one self-care management task in a controlled environment. We can use the IVR grocery store to manipulate the way self-care management information is disseminated and measure how it affects a patient's ability to care for themselves. Further, we can introduce distractions, stresses, and challenges that mimic real-world interruptions in a standardized manner. In this way, we can evaluate emotional as well as cognitive processes that influence completion of shopping tasks. With the capacity to observe participants' use of labels and, ultimately, the items purchased, it is possible to gain an understanding of how those individuals process information about sodium or other nutritional elements.


The accurate and sustained use of medication dispensing devices, such as a pill box, is a challenge for patients despite educational and demonstrative intervention by nurses.23 Our IVR kitchen environment will simulate a pill box filling scenario so that the research team can study the physical, cognitive, and behavioral challenges associated with the proper use of this important device for safe, at-home medication administration. Conducting these studies in an IVR environment that affords stability, reproducibility, and familiarity may yield new insights and new interventions.


To study self-care management tasks in IVR, the environment must have the ability to support complex interactions between participants and objects in the environment.9 The power of IVR for use in healthcare is not found solely in the technology, but rather in the partnership between the technology and the quality of the content in the environment.7 For example, specific design requirements such as the ability to visually present nutrition labels may become a problem in virtual environments if the quality of the graphics is insufficient to read the label text. However, a participant's ability to read and interact with nutrition labels is essential to the study of dietary restricted shopping. Knowing these requirements and potential pitfalls enables the team to design multiple possible solutions that can be beta tested for optimization prior to study implementation.


In this phase of our work, we focused on the expert opinions and broad perspectives provided to us by home care nurses with extensive experience in this field. We did not engage individual patients or other potential users of the environments. However, we recognize that this is a crucial next step in understanding these challenges and creating an IVR intervention that meets the diverse needs of our target user group. Input from a larger number of home care nurses in our key informant interviews could also have provided greater information on potential challenges that patients and caregivers face. We think that the process of engaging key informants in this work increases the likelihood of developing research environments that have practical implications for home healthcare nurses. Additionally, people with chronic illness often have formal and/or informal caregivers who assist with the activities highlighted in this article; therefore, they could conceivably benefit from simultaneous inclusion in the IVR environment. Our key informants were never explicitly asked about caregivers. Although we recognize that caregivers play an important role in the lives of many people with chronic illness, this scenario was beyond the scope of our current efforts.


We acknowledge that self-care challenges are multifaceted and therefore recognize that our workflow analyses are not fully comprehensive of the challenges we chose to explore. When creating our workflow analyses and design specification tables, we had to omit details that could require an interaction between multiple environments. Additionally, these workflows only incorporate one way to complete a task when there may be multiple alternatives. The limitations of our early work will be addressed during development and usability testing of the environments. The successful development of IVR environments for use with patients should incorporate user-centered design methods such as subject matter expert (key informant) interviews followed by the systematic integration of the subject matter expert knowledge into workflow analyses and design requirements. Subsequent efforts will include participatory design sessions, usability evaluation, and end-user feedback.


Although we are in the early stages of learning the possibilities of leveraging IVR for patient care in the home or community, utilizing an IVR environment in this domain possesses several opportunities.


Our future research efforts will evaluate how the IVR platform can be leveraged to improve health outcomes. We will explore the use of interactive simulations that represent common healthcare challenges in the homes of people with chronic illness. Using IVR, we will examine novel questions of disease-management and home-based nursing care in patients transitioning from acute care to outpatient environments.



The authors would like to acknowledge the team at the National Institute of Nursing Research, AVB for their participation and contribution to this work. Also, a very special thank you and recognition to the home care nurses whose clinical knowledge and expertise were essential to the overall quality and realism of the developing IVR environment.




1. Garrett B, Taverner T, Gromala D, Tao G, Cordingley E, Sun C. Virtual reality clinical research: promises and challenges. JMIR Serious Games. 2018;6(4): e10839. doi:. [Context Link]


2. Snoswell AJ, Snoswell CL. Immersive virtual reality in health care: systematic review of technology and disease states. JMIR Biomedical Engineering. 2019;4(1). doi:. [Context Link]


3. Ambron E, Miller A, Kuchenbecker KJ, Buxbaum LJ, Coslett HB. Immersive low-cost virtual reality treatment for phantom limb pain: evidence from two cases. Frontiers in Neurology. 2018;9: 67. doi:. [Context Link]


4. Garrett B, Taverner T, McDade P. Virtual reality as an adjunct home therapy in chronic pain management: an exploratory study. JMIR Medical Informatics. 2017;5(2): e11. doi:. [Context Link]


5. Birnie KA, Kulandaivelu Y, Jibb L, et al. Usability testing of an interactive virtual reality distraction intervention to reduce procedural pain in children and adolescents with cancer [formula: see text]. Journal of Pediatric Oncology Nursing. 2018;35(6): 406-416. doi:. [Context Link]


6. Andersen SAW, Konge L, Sorensen MS. The effect of distributed virtual reality simulation training on cognitive load during subsequent dissection training. Medical Teacher. 2018;40(7): 684-689. doi:. [Context Link]


7. Freeman D, Reeve S, Robinson A, et al. Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine. 2017;47(14): 2393-2400. doi:. [Context Link]


8. Davis RL. Exploring possibilities: virtual reality in nursing research. Research and Theory for Nursing Practice. 2009;23(2): 133-147. doi:. [Context Link]


9. Brennan PF, Ponto K, Casper G, Tredinnick R, Broecker M. Virtualizing living and working spaces: proof of concept for a biomedical space-replication methodology. Journal of Biomedical Informatics. 2015;57: 53-61. doi:. [Context Link]


10. Li CC, Chang SR, Shun SC. The self-care coping process in patients with chronic heart failure: a qualitative study. Journal of Clinical Nursing. 2019;28(3-4): 509-519. doi:. [Context Link]


11. Nordfonn OK, Morken IM, Bru LE, Husebo AML. Patients' experience with heart failure treatment and self-care-a qualitative study exploring the burden of treatment. Journal of Clinical Nursing. 2019;28(9-10): 1782-1793. doi:. [Context Link]


12. Granger BB, Sandelowski M, Tahshjain H, Swedberg K, Ekman I. A qualitative descriptive study of the work of adherence to a chronic heart failure regimen: patient and physician perspectives. The Journal of Cardiovascular Nursing. 2009;24(4): 308-315. doi:. [Context Link]


13. Gallacher K, Morrison D, Jani B, et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research. PLoS Medicine. 2013;10(6): e1001473. doi:. [Context Link]


14. Gardsten C, Blomqvist K, Rask M, Larsson A, Lindberg A, Olsson G. Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: a multistage focus group study. Journal of Clinical Nursing. 2018;27(19-20): 3666-3678. doi:. [Context Link]


15. Xu J, Arruda S, Gallo JJ, et al. Using vignettes to understand heart failure self-care. Journal of Clinical Nursing. 2018;27(19-20): 3554-3560. doi:. [Context Link]


16. Melby L, Obstfelder A, Helleso R. "We tie up the loose ends": homecare nursing in a changing health care landscape. Global Qualitative Nursing Research. 2018;5: 2333393618816780. doi:. [Context Link]


17. Schnall R, Rojas M, Bakken S, et al. A user-centered model for designing consumer mobile health (mHealth) applications (apps). Journal of Biomedical Informatics. 2016;60: 243-251. doi:. [Context Link]


18. Traynor M. Focus group research. Nursing Standard. 2015;29(37): 44-48. doi:. PMID: 25967446. [Context Link]


19. Cossham A, Johanson G. The benefits and limitations of using key informants in library and information studies research. Information Research. 2019;24(3). [Context Link]


20. Dym C, Little P, Orwin EJ. Engineering Design: A Project-Based Introduction. New York: Wiley; 2013. [Context Link]


21. Hope CJ, Wu J, Tu W, Young J, Murray M. Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure. American Journal of Health-System Pharmacy. 2004;61(19): 2043-2049. doi:. [Context Link]


22. Petersen ML, Wang Y, Van der Laan MJ, Guzman D, Riley E, Bangsberg DR. Pillbox organizers are associated with improved adherence to HIV antiretroviral therapy and viral suppression: a marginal structural model analysis. Clinical Infectious Diseases. 2007;45(7): 908-915. doi:. [Context Link]


23. Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database of Systematic Reviews. 2014;4: CD007768. doi:. [Context Link]


24. Sheehan B, Bakken S. Approaches to workflow analysis in healthcare settings. NI 2012. 2012;2012(371). [Context Link]