A qualitative inductive approach was used. According to the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines, the consolidated criteria for reporting qualitative research checklist for qualitative studies was followed during the study process [34].

A total of 9 PHNs working at three primary health care centers participated in the study. Two of the health care centers were in a midsized city in Northern Sweden and one was in a rural area in Northern Sweden. Head managers of the health care centers were asked to assist in recruiting participants, preferably varying in age and years of working experience, for an interview about eHealth. PHNs were informed in person or at staff meetings and 9 PHNs volunteered to participate. Inclusion criteria were being a registered nurse with a specialist graduate nursing diploma in primary health care nursing. The 9 participating PHNs ranged in age from 27 to 64 years (median 42) with work experience of 4-39 years (median 18) as registered nurses and 1-23 years (median 5) as PHNs.

Semistructured interviews were conducted by two of the authors (AES and AE) in 2016. An interview guide consisted of open-ended questions about the nurses’ experiences of meeting patients who present HRII during consultations. Questions from the guide included “How do you, in your everyday work, perceive patients searching for HRII?”; “What problems do you perceive?”; “What benefits do you perceive?”; and “How do patients’ presentations of HRII affect you in your everyday work?” With the interview guide as a skeleton, follow-up questions were asked and participants were encouraged to give several examples of their experiences. The recorded interviews, which were rich in data, lasted from 30 to 60 minutes (median 50) and were transcribed verbatim.

The interviews were analyzed using qualitative content analysis as described by Graneheim and Lundman [35]. Initially, the data were read thoroughly to acquire a basic understanding of the content. Text that corresponded to the aim was divided into meaning units and condensed (ie, shortened, but with the core message kept). The condensed meaning units were interpreted and labeled with codes. All authors discussed the codes and, based on similarities and differences, three categories and nine subcategories were identified. The authors continuously discussed the coding and categorization until consensus was achieved, which strengthens the study’s trustworthiness [36].

The study was conducted according to the ethical principles described in the Helsinki declaration [37]. Participants were provided with information about the study, both verbally and in a written letter. Participation in the study was voluntary, and the participants were informed that they could withdraw at any time without stating any reason. Informed consent was obtained from both participants and managers of the primary health care centers. Data material and personal information have been handled confidentially. The Regional Ethical Review Board at Umeå University approved the study (approval number: 2014-179-31M).

The PHNs unanimously described consultations with Internet-informed patients as common in their everyday work. Internet-informed patients were described to be of all ages, although mainly of working age. The analysis of the interviews resulted in three categories: (1) Facing the downsides of Googling, (2) Patients as main actors, and (3) Nurse role challenged. Each category consisted of three subcategories. The theme that emerged and encapsulated the essence of experiences related by the PHNs was Internet-informed patients change the rules of the game (see Table 1). Each subcategory in the following sections is illustrated with a quotation.

The overarching theme, Internet-informed patients change the rules of the game, summarizes the interpreted essence of the PHNs’ experiences of the considerable influence of HRII and knowledgeable patients on health care consultations. This influence was described to generate changes in patients’ behaviors, patterns of interaction during consultations, and the roles of patients and PHNs. The overall experiences and attitudes toward these changes were marked by ambivalence, although the problems were made very explicit.

The PHNs in our study thought that Internet-informed patients had changed the usual rules of health care. These changes were seen in patient attributes, patterns of interaction during consultations, and the roles of patients and PHNs. The benefits of HRII were described, but its negative consequences and difficulties were emphasized overall. Our results, therefore, show more negative attitudes among nurses to the phenomenon of Internet-informed patients than previous research with the same focus [30,31].This is in line with a study by Öberg et al, who found ambivalent perceptions among PHNs of the digitalization of health care [38].

The PHNs in our study distinguished clearly between different qualities of HRII, considering reliable HRII favorable and unreliable HRII unfavorable. Previous studies have shown that the accuracy and quality of patient-presented HRII is relevant to HCPs’ attitudes [28,30]. Like HCPs in previous studies [12,29], the PHNs in our study considered evidence-based HRII beneficial for its contribution to well-prepared patients and, therefore, more structured and fruitful consultations.

One finding in our study was that having HRII, patients challenged the nurse’s role. HRII has been described as transforming patients from passive recipients to active consumers of health information [11] and the patient-HCP relationship to more of a partnership [12,29]. This transformation is in line with the efforts of policy makers and health care systems toward increasingly person-centered care [17]. The PHNs in our study were unanimously positive toward increased patient involvement and the person-centered approach, although there seemed to be a fine line between patients being moderately involved and being overly involved. Humble expressions of involvement were described as favorable for both patients and health care systems; however, expressions of lay expertise and overinvolvement coupled with a lack of medical competence were perceived as problematic. Disagreements arising from patients’ presentations of false or inaccurately interpreted HRII were highlighted as challenging by the PHNs of this study, as similarly described in previous research [29,39,40]. The PHNs in our study emphasized the importance of supporting positive encounters by showing respect for patients’ opinions. This approach is in line with previous research, which suggests the importance both of acknowledging patients’ efforts to acquire knowledge and of clearly explaining the reason for divergent opinions in order to give patients a positive experience and increase the chances of patients accepting the HCPs’ advice [41,42].

The Internet has been described as a catalyst for shifting power in HCP-patient interactions, which can be regarded as a threat toward HCPs’ medical authority [11,43]. HCPs’ negative feelings about conferring with patients equipped with HRII knowledge, previously reserved for HCPs, have been attributed to perceptions of being undervalued, perceived as incompetent, or losing control of the consultation [44]. Similarly, the PHNs in our study described the lay expert role of Internet-informed patients as challenging, as it caused them to feel that their professional knowledge was being questioned, which was especially stressful when they lacked full knowledge of a specific topic. This confirms a study by Öberg et al, in which PHNs also described negative feelings about being questioned and feeling insecure when meeting well-informed patients [38]. The PHNs in our study emphasized the importance of admitting when they lacked knowledge, an attribute of HCPs that Internet-informed patients value and consider to strengthen the patient-HCP relationship [12]. HCPs who act in patriarchal ways and are unwilling to admit a lack of knowledge, on the other hand, have been shown to negatively affect patient experiences [41].

The PHNs in our study were also concerned about HRII as a potential source of negative effects on patients. Free Googling, a well-documented and dominant first strategy for patients who search for HRII [26,45,46], was emphasized as a common generator of confusion and anxiety among patients. Symptom inquiries in search engines like Google often return high rates of statistically unlikely results (eg, a headache signaling a brain tumor) [47], according to the nurses in our study, and caused notable unfounded patient anxiety. Increased anxiety after searching for HRII, especially in health-anxious people, has been reported in several studies as cyberchondria [48-50]. HCPs have been advised to either counsel health-anxious patients to avoid HRII [48,51] or to actively guide them to credible websites [47,52]. The PHNs’ perception that parents of toddlers are high consumers of HRII, particularly inclined to insecurity and anxiety, is in line with a study by van der Gugten et al [53]. The PHNs’ concerns about the negative effects of HRII searches on patients are confirmed by research and appear legitimate.

The PHNs suggested equality in care as a benefit of reliable HRII, as it offers everyone access to the same information. However, considering the PHNs’ experiences of patients having problems with HRII and other research that shows low levels of health literacy [22,23], it is probably pertinent to ask how to achieve equitable care. In consultations with Internet-informed patients, promoting equitable care would mean enabling patients with varying predispositions to partake in the general information supply. The PHNs’ described shift in roles and tasks, moving from controlling to coaching increasingly knowledgeable patients, seems to be a step in this direction. Dickerson et al also described how the Internet had changed nurses from educators to knowledge consultants [54]. Previous research has suggested different approaches for coaching patients’ HRII use. Since misconceptions easily arise from inaccurate HRII and poor levels of eHealth literacy, previous studies have emphasized the importance of HCPs in facilitating and encouraging open discussions about HRII [26,39,55]. Active assessment of patients’ use of HRII has been recommended as valuable [13]. Guiding patients to credible websites is also important to ensure that they obtain reliable information and to minimize confusion, anxiety, or poor health decisions based on contradictory information or misunderstood medical jargon [11,31,45]. Research into patients’ views has shown a desire for such navigational help from HCPs [26,56,57]. Since HRII is broad and general, HCPs could play an important role in contextualizing the HRII to the patient’s personal situation [26,53]. It has been suggested that nurses occasionally visit the most popular parenting forums for updates on current health questions, since parents often leave these sites confused by conflicting information [58]. It is also important for HCPs to be aware that even though most patients obtain and are influenced by HRII, far from all of them mention this information to their HCP. Such reluctance may be due to fear of being perceived as challenging, previous bad experiences of presenting HRII, fear of embarrassment, or the perception that the HRII is not important enough [28,39]. Patients with navigational needs have been shown to be less likely to discuss their Internet findings [59], a fact that supports the importance of HCPs actively encouraging discussions about HRII.

This study offers both strengths and limitations. The participating PHNs were varied in age and years of professional experience, which strengthens the trustworthiness and transferability of our results [36]. All the participating PHNs were women, which could be considered a limitation. However, most Swedish PHNs are women [60], which should make the results transferable in this context. There is a possibility that PHNs with stronger views on the subject of eHealth were more likely to volunteer for the study, which could represent a bias.

Because they are in accord with previous research, some aspects of our results are also considered transferable to other health care professions. The interviews offered rich data, and saturation was considered reached by the last interviews.

Because four of the study authors are PHNs, like the participants, reflexivity was considered throughout the research process. Familiarity with the attributes of participants can contribute to a better in-depth understanding of the participants’ experiences, but we were alert to avoiding our own projections during the process. In order to consider different perspectives, continuous discussions were held within the research group [61]. All authors were involved in the analytical process, which is considered to strengthen the trustworthiness of the study.

PHNs and other HCPs are encouraged to actively raise discussions about patients’ perceptions of HRII, help patients to evaluate and contextualize their Internet findings, and guide patients to credible and evidence-based websites.

This study implies that the phenomenon of Internet-informed patients affects the everyday work and professional role of PHNs. Further research is needed to make a profound analysis of the mechanisms behind ambivalent attitudes, for example, regarding concepts like power and professional identity, and how attitudes are linked to perceptions of patients’ eHealth literacy levels. Future studies will also explore PHNs’ Internet use and eHealth literacy and how these factors affect attitudes toward Internet-informed patients.

This study suggests that PHNs are ambivalent about working with Internet-informed patients. While they expressed fundamentally positive attitudes toward increased patient involvement and patient-centered interactions, these attitudes were somewhat overshadowed by reported negative perceptions of the effects and consequences of HRII. Accurate and correctly managed HRII has been shown to offer many possible advantages for patients and health care systems. However, the negative attitudes and apprehensions of HCPs about Internet-informed patients could obstruct the development of increased patient involvement. To promote equitable care in the digital era, increased awareness in health care about useful strategies for overcoming difficulties and embracing benefits of HRII seems to be a legitimate goal.